ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
Extract:
Question 1 of 5
A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?
Correct Answer: B
Rationale: Agranulocytosis, a clozapine side effect, causes sore throat and muscle aches due to reduced infection-fighting ability. Respiratory depression (
A), anxiety (
C), and restlessness (
D) are unrelated.
Question 2 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 3 of 5
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
Correct Answer: A,C
Rationale: Blunt affect (
A) and anhedonia (
C) are negative symptoms. Delusions (
B), hallucinations (
D), and poor judgment (E) are not negative symptoms.
Question 4 of 5
A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?
Correct Answer: B
Rationale: Neuroleptic malignant syndrome causes hyperpyrexia, unstable blood pressure, and diaphoresis. Pseudoparkinsonism (
A), acute dystonia (
C), and tardive dyskinesia (
D) do not typically include these symptoms.
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.