ATI Custom NUR175 Exam 1 Summer ASN Part 1
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Nurse's Notes: The client was brought to the emergency department after his coworker saw the client wandering in the parking lot, talking to himself. The client was pacing back and forth across the parking lot, and his words did not make sense. Currently, the client is alert and restless. He verbalizes that he has not felt the need to sleep in 3 days and feels full of energy. The client is suspected to be experiencing a manic episode.
Mental Status Assessment: Alert. Restlessness, pacing. Rapid, pressured speech. Grandiose. Memory intact. Judgment poor. No suicidal or homicidal thoughts.
Select 3 recommended nursing interventions for this client from the list below.
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Place the client in a quiet, low-stimulation environment.
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Invite the client to journal their thoughts to encourage emotional expression.
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Encourage the client to rest in bed until their energy levels stabilize.
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Assign a consistent staff member to interact with the client.
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Offer finger foods and fluids the client can consume while pacing.
Explanation
Correct Answer: (A) Place the client in a quiet, low-stimulation environment, (D) Assign a consistent staff member to interact with the client, and (E) Offer finger foods and fluids the client can consume while pacing. A quiet, low-stimulation environment helps reduce excessive external stimuli that can worsen agitation and restlessness in a manic client. Assigning a consistent staff member provides structure, promotes trust, and helps maintain consistent limit-setting given the client's poor judgment. Offering finger foods and fluids the client can consume while pacing addresses the client's nutritional and hydration needs, since the client's constant motion and poor concentration make sitting down for a full meal unrealistic at this time.
Why Other Options are Incorrect:
B. Inviting the client to journal their thoughts to encourage emotional expression is not appropriate at this time, as the client's pressured speech, poor judgment, and racing thoughts make it unlikely they could engage in a structured reflective activity; this intervention also does not address the client's immediate safety and physiological needs.
C. Encouraging the client to rest in bed until their energy levels stabilize is unrealistic during acute mania, as the client's excessive energy and restlessness make it very difficult to remain still; forcing this expectation may increase frustration rather than promote stabilization.
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"Let me call your healthcare provider so you can ask what they think you should do."
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"You should start the medication as soon as possible to slow the disease."
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"You probably do not need medication if you are questioning it."
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"I can give you information about the medication so you can decide what's best for you."
Explanation
Correct Answer: (D) "I can give you information about the medication so you can decide what's best for you."
Autonomy is the ethical principle that supports a client's right to make informed decisions about their own healthcare. This response best supports autonomy by offering to provide the information the client needs to make a well-informed, independent decision without directing, pressuring, or undermining their ability to choose. Informed decision-making is the cornerstone of respecting patient autonomy.
Why the other options are incorrect:
A. Deferring entirely to the healthcare provider without first providing available information is not the most supportive response for autonomy. The nurse has a professional responsibility to educate the client and facilitate informed decision-making directly.
B. Telling the client they should start the medication as soon as possible is directive and does not respect the client's right to weigh their options. It prioritizes compliance over autonomy.
C. Suggesting the client probably does not need medication if they are questioning it is clinically irresponsible and potentially harmful. It discourages evidence-based treatment based on the client's uncertainty rather than clinical need.
Medical History: Borderline personality disorder. Anorexia nervosa. Medication: fluoxetine 20 mg PO daily.
Nurses' Notes — 1000: The client was admitted for evaluation and treatment following referral by her family provider, due to continued weight loss and deteriorating school performance. The client reports joining the swim team and insists that she needs to lose 30 lbs to be competitive and make it to the state swim meet next year. The client states, "I hate my ugly body." Parents report the client refuses to eat with the family. She has been following a YouTube influencer who teaches young girls how to lose weight and stay spring-break ready.
Nurses' Notes — 1800: Noted that the client only ate 15% of her dinner meal. She requested to go to the bathroom, and the assistive personnel was asked by the nurse to accompany her. In the bathroom, the client refused to use the bathroom if the assistive personnel did not leave and lock the door behind her.
Vital Signs: Temperature 35.8 °C (96.4 °F); Heart Rate 58/minute; Blood Pressure 78/52 mm Hg; Respiratory Rate 22/minute; Body Mass Index (BMI) 16.
For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.
Explanation
Encouraging the client to talk about her feelings and establishing trust are indicated because therapeutic communication and rapport are foundational to helping a client with anorexia nervosa address the distorted body image and underlying emotional struggles driving her restrictive behaviors. Staying with the client during meals and for 2 hours after is indicated because it allows the nurse to monitor intake and prevent purging or other compensatory behaviors, which is especially critical given the client's already unstable vital signs. Allowing client privacy in the bathroom after meals is contraindicated because unsupervised bathroom access creates an opportunity for purging behavior, which is reinforced by the client's own request to have the door locked with no supervision. Providing a treadmill for unlimited exercise is contraindicated because the client's bradycardia, hypotension, and low BMI reflect a fragile physiological state, and excessive exercise would further compromise her cardiovascular status and reinforce compulsive weight-loss behavior. Playing the client's favorite music during meals is nonessential because, while it may create a more pleasant environment, it does not directly address the client's physiological or psychological safety needs at this time.
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Psychoanalysis therapy
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Systematic desensitization
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Operant conditioning
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Cognitive therapy
Explanation
Operant conditioning is a behavioral therapy technique in which behavior is modified through the use of rewards and punishments. In this scenario, the client receives a small reward each day for not smoking, which is a positive reinforcement strategy designed to increase the likelihood of the desired behavior being repeated. This is a classic example of operant conditioning as described by B.F. Skinner.
Why the other options are incorrect:
A. Psychoanalysis therapy focuses on exploring unconscious thoughts, past experiences, and unresolved conflicts to understand and treat psychological distress. It does not involve reward-based behavioral modification.
B. Systematic desensitization is a behavioral technique used to treat phobias and anxiety by gradually exposing the client to a feared stimulus while pairing it with relaxation techniques. It does not involve rewards for behavior change.
D. Cognitive therapy focuses on identifying and restructuring maladaptive thought patterns and beliefs that contribute to emotional distress and unhealthy behaviors. It does not involve tangible reward systems for behavioral compliance.
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Clonazepam
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Chlorpromazine
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Risperidone
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Sertraline
Explanation
Correct Answer: (D) Sertraline
Sertraline is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed as first-line treatment for major depressive disorder because it increases serotonin availability in the brain, helping to improve mood, energy, and overall depressive symptoms.
Why the other options are incorrect:
Clonazepam is a benzodiazepine used primarily for anxiety and seizure disorders, not as a treatment for depression, and carries risk of dependence with long-term use.
Chlorpromazine is a typical antipsychotic used to manage symptoms of schizophrenia and severe agitation, not depression.
Risperidone is an atypical antipsychotic used to treat schizophrenia and bipolar disorder, and while it may be used as an adjunct in treatment-resistant depression, it is not the medication most likely anticipated for a client simply diagnosed with major depressive disorder.
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Stevens-Johnson syndrome
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Hypertensive crisis
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Neuroleptic malignant syndrome
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Serotonin syndrome
Explanation
Correct Answer: (C) Neuroleptic malignant syndrome
Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medications such as chlorpromazine. Its hallmark presentation includes hyperthermia, severe muscle rigidity, autonomic instability such as elevated blood pressure and heart rate, and altered mental status including confusion. The temporal relationship between chlorpromazine administration and symptom onset makes NMS the primary suspect.
Why the other options are incorrect:
A. Stevens-Johnson syndrome is a severe skin reaction typically caused by medications such as anticonvulsants or antibiotics, characterized by widespread skin blistering and mucous membrane involvement. It does not present with muscle rigidity and autonomic instability.
B. Hypertensive crisis involves severely elevated blood pressure but does not explain the combination of high fever, muscle rigidity, and confusion following antipsychotic administration.
D. Serotonin syndrome shares some features with NMS, including hyperthermia and autonomic instability, but is caused by excess serotonergic activity from serotonergic medications such as SSRIs or MAOIs, not from antipsychotics like chlorpromazine. Muscle rigidity in NMS also tends to be more severe and described as lead-pipe rigidity, distinguishing it from the neuromuscular hyperactivity seen in serotonin syndrome.
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Collaborate with the dietitian to offer high-calorie snacks the client prefers.
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Monitor vital signs and electrolyte levels closely during the refeeding process.
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Encourage the client to discuss feelings about body image during therapy.
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Provide privacy during mealtimes to reduce anxiety.
Explanation
Correct Answer: (B) Monitor vital signs and electrolyte levels closely during the refeeding process.
Clients with severe anorexia nervosa are at significant risk for refeeding syndrome, a potentially fatal complication involving dangerous electrolyte shifts when nutritional intake resumes after prolonged starvation; therefore, close monitoring of vital signs and electrolytes is the priority to detect and prevent life-threatening cardiac and metabolic complications.
Why the other options are incorrect:
A. Collaborating with the dietitian to offer high-calorie snacks the client prefers is an important part of nutritional rehabilitation, but it does not take priority over the physiological safety concern of monitoring for refeeding syndrome.
C. Encouraging the client to discuss feelings about body image during therapy addresses important psychological aspects of anorexia nervosa, but it is not the priority given the client's severe physical compromise.
D. Providing privacy during mealtimes to reduce anxiety may be a helpful supportive measure, but it does not address the urgent physiological risk associated with refeeding.
Medical History: Client admitted through the emergency department to the inpatient unit after he punched his sister on the face and grabbed a knife and tried to stab his mother. Recently he was involved in an altercation on a public bus with a passenger he claimed was "looking at me in a mean way." Mother reports he has not been taking his medications in the last few months. She reports he has been so agitated at times that he escalates to aggression directed towards whoever is around. Mother reports, "It has been getting harder and harder to deal with him. Everyone is scared he might hurt someone real bad."
Mental Status: Appearance: unkempt, appropriate for age. Level of consciousness: alert. Mood: labile. Insight: poor. Thought process and content: paranoid, delusional. Judgment: poor.
Progress Notes — Day 1: Client agitated during admission. Says to the nurse, "Tell these people to leave me alone. I am not crazy." Nurse interacts with client in a therapeutic way. Client finally settles into a private room. Nurse inspects his belongings for any items that can be used to harm self or others. Client continues to complain that he is not crazy and that his family are "just an unreasonable bunch." Nurse gives ordered STAT medications and discusses with client about plan of care to help him stabilize.
Progress Notes — Day 2: Client resting in his room. When nurse enters the room for morning medication, client refuses medication, stating, "I am not crazy." Nurse notices that client is talking softly to himself, saying, "They need to be put in their place. They are evil. I can't stand them."
Progress Notes — Day 3: Client still in his room, refuses to get out of the room when invited to join the rest of clients for a group sessio
Select the priority nursing problem the client is most likely experiencing, 2 actions the nurse should take, and 2 parameters the nurse should monitor.
Priority Client Problem
- Malnutrition
- Violence directed towards others
- Violence directed towards self
- Family dysfunction
- Administer PRN olanzapine
- Place client in a seclusion room
- Restrain the client
- Ignore client's outbursts
- Homicidal thoughts
- Early signs of agitation
- Dehydration
- Attention-seeking behaviors
Explanation
Correct Answer: (B) Violence directed towards others.
The client's history of physically assaulting his sister, attempting to stab his mother, altercation with a stranger on a bus, paranoid and delusional thought content, medication non-adherence, and escalating aggression toward others directly indicate a priority risk for violence directed towards others.
Why the other options are incorrect:
A. Malnutrition is not supported by any assessment data in this scenario.
C. Violence directed towards self is not supported, as there is no evidence of suicidal ideation or self-harming behavior; all aggressive behaviors described are directed outward toward others.
D. Family dysfunction may be a contributing psychosocial stressor, but it is not the priority physical safety concern compared to the risk of violence toward others.
Actions to Take (select 2)
Correct Answer: (A) Administer PRN olanzapine and (B) Place client in a seclusion room.
Administering PRN olanzapine, an antipsychotic, helps address the client's paranoid and delusional thinking while calming agitation that could lead to violent behavior. Placing the client in a seclusion room provides a reduced-stimulation environment that helps prevent harm to other clients and staff while the client de-escalates.
Why the other options are incorrect:
C. Restraining the client is a more restrictive intervention that should only be used after less restrictive measures such as medication and seclusion have been attempted and proven ineffective.
D. Ignoring the client's outbursts is unsafe, as it fails to address escalating agitation and paranoid ideation that could result in harm to others.
Parameters to Monitor (select 2)
Correct Answer: (A) Homicidal thoughts and (B) Early signs of agitation.
Monitoring for homicidal thoughts is essential given the client's history of attempting to stab a family member and expressing hostility toward others, as ongoing assessment helps determine the client's current risk level. Monitoring for early signs of agitation allows the nurse to intervene proactively before the client's behavior escalates to violence.
Why the other options are incorrect:
C. Dehydration is not indicated by any findings in this scenario and is not the priority parameter to monitor.
D. Attention-seeking behaviors are not relevant to this client's presentation, which is centered on paranoia, delusions, and risk for violence rather than attention-seeking behavior.
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Explain to the client that hallucinations are a symptom of their illness and that medication will help.
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Ask the client, "Can you tell me more about what the voices are saying to you?"
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Redirect this client's thought process by implementing a structured activity.
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Reassure the client by saying, "Nothing bad is going to happen. The voices aren't real."
Explanation
Correct Answer: (B) Ask the client, "Can you tell me more about what the voices are saying to you?"
Asking the client to elaborate on the content of the hallucinations allows the nurse to assess for safety concerns, such as command hallucinations instructing the client to harm themselves or others, while also validating the client's experience in a therapeutic, non-judgmental manner.
Why Other Options are Incorrect:
A. Explaining that hallucinations are a symptom of their illness and that medication will help is educational but does not address the immediate need to assess the content and safety risk of the current hallucination.
C. Redirecting the client's thought process by implementing a structured activity may be useful once safety has been assessed, but doing so before evaluating the content of the voices risks missing a potential safety threat.
D. Reassuring the client by saying "nothing bad is going to happen" and that the voices aren't real dismisses the client's experience and is not therapeutic, as arguing about the reality of hallucinations can damage trust and does not address safety.
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Place the client in seclusion to reduce environmental stimulation.
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Implement one-to-one supervision to monitor for escalating agitation.
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Administer mood stabilizers as prescribed and reassess in 30 minutes.
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Encourage the client to join a group activity to channel excess energy.
Explanation
Correct Answer: (B) Implement one-to-one supervision to monitor for escalating agitation A client in the manic phase who has not eaten in 24 hours and is exhibiting escalating psychomotor activity (rapid pacing, pressured speech, interrupting others) is at risk for physical exhaustion, dehydration, and further escalation into dangerous agitation, making close, continuous monitoring through one-to-one supervision the priority to ensure the client's immediate safety while other needs such as nutrition are addressed.
Why the other options are incorrect:
A. Place the client in seclusion to reduce environmental stimulation: Seclusion is a restrictive intervention reserved for situations where the client poses an immediate danger to self or others and less restrictive measures have failed; it is not the first-line priority action for a client who is simply hyperactive and has not yet demonstrated danger requiring this level of restriction.
C. Administer mood stabilizers as prescribed and reassess in 30 minutes: While medication management is an important part of the overall treatment plan, mood stabilizers take time to reach therapeutic effect and do not address the immediate safety concern of a client at risk for exhaustion and escalating agitation right now.
D. Encourage the client to join a group activity to channel excess energy: Group activities involve increased stimulation and social interaction, which can actually worsen mania by further escalating the client's agitation and hyperactivity rather than promoting stabilization.
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