ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
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Client appears withdrawn and does not engage in conversation.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 1 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Rationale: Withdrawn (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:
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 2 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.
Extract:
Question 3 of 5
A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: Having consistent unit routines provides stability and predictability, beneficial for mania. Stimulating environments (
B) can worsen symptoms, seclusion (
C) may cause isolation, and discouraging napping (
D) risks fatigue.
Question 4 of 5
A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?
Correct Answer: B
Rationale: Positive feedback for assertiveness encourages independence. Self-mutilation (
A) relates to other disorders, flamboyance (
C) to histrionic, and exploitation (
D) to antisocial.
Question 5 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.