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 is experiencing suicidal thoughts. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: Removing harmful objects minimizes self-harm risk. Twelve-hour observation (
A) may be insufficient, and unregulated visitors (C,
D) risk bringing harmful items.
Extract:
A nurse is caring for a client who has schizophrenia.
Nurses' Notes: Day 1 1030: A 35-year-old client who has schizophrenia is admitted.
Diagnosed 15 years ago.
Brought in by partner and states client has remained in room for the last several days and movements are delayed.
Day 1 1730: Client refuses to eat or drink.
Client appears withdrawn and does not engage in conversation.
Client has flat affect.
Does not want to go to therapy session and wants to sleep.
Client's movements are slow.
Vital Signs: Day 1 1030: Temperature 37° C (98.6° F). Heart rate 72/min.
Respiratory rate 20/min.
Blood pressure 132/38 mm Hg. Oxygen saturation: 99% on room air.
Question 2 of 5
Select the '3' findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia:
Correct Answer: A,B,D
Rationale: Withdrawn (
A), lack of energy (
B), and lack of motivation (
D) are negative symptoms. Change in behavior (
C) is broad, and blood pressure (E) is physiological.
Extract:
Question 3 of 5
A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?
Correct Answer: D
Rationale: A WBC of 2,900 cells/mm^2 indicates possible agranulocytosis, requiring clozapine discontinuation. BUN (
A), potassium (
B), and hematocrit (
C) are not contraindications.
Question 4 of 5
A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?
Correct Answer: A
Rationale: A lithium level of 1.6 mEq/L, above therapeutic range, causes GI discomfort and poor coordination. Lip smacking (
B), jerking movements (
C), and fever (
D) are unrelated.
Question 5 of 5
A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?
Correct Answer: B
Rationale: Offering a choice promotes autonomy and encourages self-care. Confrontation (
A), forcefulness (
C), and ignoring (
D) are unhelpful.