ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Blurred vision and ataxia indicate lithium toxicity, so the nurse should withhold the medication. Administering the next dose (
B) risks worsening toxicity, propranolol (
C) is irrelevant, and levothyroxine (
D) is for hypothyroidism.
Question 2 of 5
A nurse is discussing schizophrenia spectrum disorders with a client. The client states, 'My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: Isolation in the prodromal phase is an early schizophrenia warning. General uncertainty (
A), introversion (
B), and avoiding friends for voices (
D) are less accurate.
Question 3 of 5
A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?
Correct Answer: A
Rationale: Muscle weakness indicates mild lithium toxicity. Constipation (
B), urinary retention (
C), and hyperactivity (
D) are not typical symptoms.
Question 4 of 5
A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Weight gain is a common side effect of risperidone. Bradycardia (
B), nightmares (
C), and edema (
D) are not typical.
Extract:
Medication Administration Record
• Naltrexone 50 mg PO once daily.
• Fluoxetine 20 mg PO every morning.
Diagnostic Results
• Hepatitis Viral Study (HAA): Positive (Expected Reference Range: Negative)
• Sodium Level: 131 mEq/L (Expected Reference Range: 136 to 145 mEq/L)
• Calcium Level: 9.5 mg/dL (Expected Reference Range: 9 to 10.5 mg/dL)
• BUN (Blood Urea Nitrogen): 11 mg/dL (Expected Reference Range: 10 to 20 mg/dL)
• Fasting Blood Glucose Level: 82 mg/dL (Expected Reference Range: 74 to 106 mg/dL)
• Hematocrit (Hct): 44% (Expected Reference Range: 37 to 52%)
• Hemoglobin (Hgb): 14 g/dL (Expected Reference Range: 12 to 18 g/dL)
History and Assessment
• Client has been admitted to the facility three times within the last 12 months.
• Client shows marked emotional lability and difficulty controlling their impulses.
• Client reports having multiple sexual partners and denies use of condoms.
• Client also acknowledges spending "a lot of money lately" and is not sure how they will pay for their current bills.
• Client admits to participating in self-harming behaviors (cutting) in the past to soothe themselves when feeling anxious.
• No evidence of recent self-harm.
• Client has recently experienced the loss of their remaining living parent and has reported an increased use of alcohol and recreational intravenous drugs to "numb the pain.”. Nurses Notes: Skin is warm and dry.
• Sclera are bloodshot.
• Client is unsteady on their feet, restless, and tense.
• Client reports drinking "a lot of whiskey" within the last 24 hrs.
• Presence of alcohol noted on the client's breath.
• Client is asking for "my nerve" pill.
• Evidence of old healed scratches/cuts noted on the arms and legs.
• States, "I don't have any money to pay for this!" When asked about living family members, states, "everyone is dead, life stinks.”.
Question 5 of 5
A nurse is caring for a client who has borderline personality disorder (BPD). Check the 6 assessment findings that require immediate follow-up:
Correct Answer: A,B,C,E,G
Rationale: Increased substances (
B), risky sexual behaviors (
C), positive hepatitis (
D), low sodium (G), frequent admissions (H), and loss of parent (I) require follow-up. Financial situation (
A), normal BUN (E), and Hgb (F) do not.