ATI RN
ATI RN Custom NURS 120 Psychiatric Nursing FA23 Exam 2 Questions
Extract:
Medical History: Borderline personality disorder.
Alcohol use disorder.
History of suicidal ideation.
Medication Administration Record: Fluoxetine 20 mg PO daily.
Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.
Client reports recent breakup of romantic relationship and subsequent job loss.
States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.
Client states, "I feel so alone.
Question 1 of 5
There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
| anticipated | nonessential | contraindicated |
|---|---|---|
| Instruct the client to avoid foods with tyramine. | ||
| Apply wrist restraints. | ||
| Offer sympathy and attention to maladaptive behavior. | ||
| Encourage the client to talk about feelings prior to maladaptive behavior. | ||
| Maintain same staff members caring for the client. |
Correct Answer:
Rationale: Encouraging feelings (
D) and consistent staff (E) are anticipated. Tyramine avoidance (
A) is for MAOIs, restraints (
B) are a last resort, and sympathy to maladaptive behavior (
C) reinforces negativity.
Extract:
Question 2 of 5
A nurse is talking with a client who has schizophrenia. Suddenly the client states, 'I'm frightened. Do you hear that? The voices are telling me to do terrible things.' Which of the following responses by the nurse is appropriate?
Correct Answer: A
Rationale: Asking what the voices say assesses potential danger empathetically. Questioning why (
B), denying voices (
C), or instructing to dismiss them (
D) may invalidate or distress.
Extract:
A nursing student is looking at a telemetry screen with multiple rhythms. The unit is a step-down cardiac unit with delicate patients. Patients on Census. The unit has:
1. 84-year-old male with AFib, diaphoretic, and complaining of fatigue.
2. 45-year-old female with SVT not responding to adenosine.
3. 78-year-old female with bradycardia who was given atropine and epinephrine, yet unresolved.
4. 80-year-old male in pulseless Ventricular fibrillation being coded and transferred to Intensive Care Unit.
5. 69-year-old female who arrived at the unit symptomatic and currently being coded is pulseless with Ventricular Tachycardia.
Question 3 of 5
The nurse on the step-down unit explains to the nursing student the electricity to be used for each dysrhythmia. Select the correct electricity to be used to manage the dysrhythmias listed:Transcutaneous Pacing, Defibrillation, or Synchronized cardioversion?Dysrhythmias:
| Options | Transcutaneous Pacing | Defibrillation | Synchronized cardioversion |
|---|---|---|---|
| Ventricular fibrillation | |||
| PVC-run ventricular tachycardia with a pulse | |||
| Atrial Flutter | |||
| Bradycardia |
Correct Answer:
Rationale: Ventricular fibrillation: The correct electricity is Defibrillation. Ventricular fibrillation is a life-threatening condition that requires immediate medical attention. Defibrillation is the process of delivering an electric shock to the heart to stop the fibrillation and allow the heart’s normal rhythm to resume4.
PVC-run ventricular tachycardia with a pulse: The correct electricity is Synchronized Cardioversion. This is used when the patient is hemodynamically stable. It involves the delivery of a therapeutic dose of electrical current to the heart at a specific moment in the cardiac cycle5.
Atrial Flutter: The correct electricity is Synchronized Cardioversion. Atrial flutter is a type of abnormal heart rhythm, or arrhythmia. It can be treated with synchronized cardioversion, in which a controlled electric shock is delivered to the heart to restore normal rhythm5.
Bradycardia: The correct electricity is Transcutaneous Pacing. This is a temporary means of pacing a patient’s heart during a medical emergency. It should be undertaken by healthcare providers who are trained in the procedure5.
So, the correct answer is Defibrillation for Ventricular fibrillation, Synchronized Cardioversion for PVC-run ventricular tachycardia with a pulse and Atrial Flutter, and Transcutaneous Pacing for Bradycardia, after analyzing all choices.
Extract:
Question 4 of 5
A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: B
Rationale: Vomiting is a common symptom of lithium toxicity. Flatulence (
A), loss of appetite (
C), and headaches (
D) are not specific indicators.
Question 5 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.