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 a hallucination. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Telling the client the hallucination is not real grounds them in reality. Asking questions (
A) may validate it, arguing with voices (
B) increases distress, and acting as if real (
C) reinforces the hallucination.
Question 2 of 5
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?
Correct Answer: A
Rationale: Command hallucinations can direct harm to self or others, making them the priority. Tactile (
B), gustatory (
C), and visual (
D) hallucinations are less immediately dangerous.
Question 3 of 5
A nurse is caring for a young adult client who has somatic symptom disorder and is being evaluated for chest pain. The client's laboratory results are all within the expected reference ranges, the ECG is unremarkable, and the client has no identified cardiac risk factors. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Reassurance supports the client when tests are normal, avoiding invalidation. Flooding therapy (
A) is inappropriate, saying pain isn’t real (
B) dismisses feelings, and invasive testing (
D) is unnecessary.
Question 4 of 5
A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.)
Correct Answer: B,C,D
Rationale: Muscle spasms (
B), tremors (
C), and fidgeting (D, akathisia) are EPS. Sexual dysfunction (
A) and blurred vision (E) are unrelated to EPS.
Question 5 of 5
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
Correct Answer: B
Rationale: Disorganized speech indicates acute mania, characterized by racing thoughts. Weight gain (
A), hallucinations (
C), and clothing choice (
D) are not specific to mania.