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 schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?
Correct Answer: D
Rationale: Asking what the voices say assesses for command hallucinations, prioritizing safety. Acknowledging voices (
A), linking to illness (
B), and frequency (
C) are less urgent.
Question 2 of 5
A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?
Correct Answer: D
Rationale: Sudden mood improvement may indicate suicide risk, so monitoring whereabouts ensures safety. Family outings (
A), rewarding behavior (
B), and asking why (
C) do not prioritize safety.
Extract:
A nurse in a mental health facility is caring for a client.
Medical History: Antisocial personality disorder.
Substance use disorder.
Nurses' Notes:. 1400: Client admitted to facility by court order for evaluation following arrest for disorderly conduct and resisting arrest.
Client states, "That judge is so stupid.
I don't belong here!" Client has rigid posture, is pacing around the room attempting to intimidate staff and other clients on the unit.
Extra staff members gather.
1500: Client escorted to room.
Client becomes flirtatious with assistant personnel (AP). Client introduced to roommate, whom they ignore.
Continues to flirt with AP. 1800: Client refuses to go to dining room for dinner.
States, "I'm not sitting down with a bunch of nuts.
Question 3 of 5
Bring my food to me!". For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
| anticipated | contraindicated |
|---|---|
| Use bargaining to improve behavior. | |
| Provide rewards for positive behavior. | |
| Ignore negative behavior. | |
| Maintain a low-stimuli environment. |
Correct Answer:
Rationale: Rewards for positive behavior (
B) and low-stimuli environment (
D) are anticipated for antisocial personality disorder. Bargaining (
A) reinforces manipulation, and ignoring negative behavior (
C) avoids accountability.
Extract:
Medical History: Borderline personality disorder.
Alcohol use disorder.
History of suicidal ideation.
Medication Administration Record: Fluoxetine 20 mg PO daily.
Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.
Client reports recent breakup of romantic relationship and subsequent job loss.
States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.
Client states, "I feel so alone.
Question 4 of 5
There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
| anticipated | nonessential | contraindicated |
|---|---|---|
| Instruct the client to avoid foods with tyramine. | ||
| Apply wrist restraints. | ||
| Offer sympathy and attention to maladaptive behavior. | ||
| Encourage the client to talk about feelings prior to maladaptive behavior. | ||
| Maintain same staff members caring for the client. |
Correct Answer:
Rationale: Encouraging feelings (
D) and consistent staff (E) are anticipated. Tyramine avoidance (
A) is for MAOIs, restraints (
B) are a last resort, and sympathy to maladaptive behavior (
C) reinforces negativity.
Extract:
Question 5 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.