ATI RN
ATI RN Mental Custom Health Next Gen Questions
Extract:
Question 1 of 5
Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C: Administer a medication such as benztropine IM to correct this dystonic reaction. The patient is exhibiting symptoms of acute dystonia, a side effect of haloperidol. Benztropine is a commonly used anticholinergic medication that can quickly reverse these symptoms. It is important to address this promptly to prevent further complications. Holding the medication and contacting the prescriber (choice
A) can be done after addressing the acute symptoms. Wiping the patient with cold water or alcohol (choice
B) may provide temporary relief but does not address the underlying cause. Reassuring the patient about tardive dyskinesia (choice
D) is incorrect as the current symptoms are not related to tardive dyskinesia.
Question 2 of 5
During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?
Correct Answer: B
Rationale: The correct answer is B: Remain calm and use a matter-of-fact approach. This approach is essential to provide a sense of safety and security for the client experiencing extreme anxiety. By remaining calm, the nurse can model a calming presence and help the client feel more at ease. Using a matter-of-fact approach can help normalize the situation and reassure the client that her feelings are valid but manageable.
A: Assisting the client in developing coping skills may be beneficial in the long term, but in this acute situation, the immediate focus should be on providing immediate support.
C: Asking the client why she is anxious may not be helpful as it can potentially increase her anxiety or lead to a delusional explanation.
D: Administering a sedative should not be the first intervention as it does not address the underlying cause of the anxiety and may mask important information that could help in providing appropriate care.
In summary, the most important intervention is remaining calm and using a matter-of-fact
Question 3 of 5
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
Correct Answer: A
Rationale: The correct answer is A: Acute confusion. This is the priority problem because the client is disoriented, disorganized, and confused, indicating an altered mental status requiring immediate attention. Addressing acute confusion is crucial to ensure the client's safety and well-being.
Incorrect
Choices:
B: Ineffective community coping is not the priority as the client's immediate cognitive impairment takes precedence.
C: Disturbed sensory perception does not align with the client's presentation of confusion and disorientation.
D: Self-care deficit may be a concern but is secondary to the acute confusion that needs urgent intervention.
Question 4 of 5
The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the RN to provide in this crisis?
Correct Answer: D
Rationale: The correct response is D: Call for transportation to the hospital. In this crisis situation, the most urgent need is for the employee to be with her child at the hospital. By providing transportation, the nurse ensures that the employee can reach her child quickly and offer support. This action demonstrates empathy and prioritizes the employee's immediate needs.
A: Asking the employee what she thinks should happen may not be the most appropriate response in a crisis where decisive action is needed.
B: Inquiring about the seriousness of the collision is secondary to ensuring the employee can reach her child at the hospital.
C: Asking the employee what she thinks she should do puts the onus on her to make a decision when she may be in distress and unable to think clearly.
Question 5 of 5
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
Correct Answer: C
Rationale: The correct answer is C: Disturbed sensory perception. The client's delusions and false beliefs indicate a break from reality, which is a hallmark symptom of disturbed sensory perception. This poses a risk to the client's safety and well-being. Ineffective sexual patterns (choice
A) and compromised family coping (choice
D) may be secondary to the primary issue of distorted perceptions. Impaired environmental interpretation (choice
B) is less relevant as the client's issues are more internal. Overall, addressing the disturbed sensory perception is the priority to ensure the client's safety and initiate appropriate treatment.