by ATI: Real Questions and Expert-Approved
Answers (Qualified!)
Course
Hesi
1. Q: A patient with schizophrenia is prescribed risperidone. What is a common
side effect to monitor for, especially early in treatment?
A: Extrapyramidal symptoms (EPS), including tremors, rigidity, and akathisia.
2. Q: What is the primary therapeutic goal when initiating cognitive behavioral
therapy (CBT) for a patient with major depressive disorder?
A: To identify and challenge negative thought patterns and develop healthier coping strategies.
3. Q: A client taking fluoxetine reports sexual dysfunction. What is the best
nursing intervention?
A: Discuss possible medication adjustments with the provider and suggest non-pharmacologic
strategies to manage symptoms.
4. Q: What assessment finding is most concerning in a patient taking lithium?
A: Serum lithium level above 1.5 mEq/L indicating toxicity.
5. Q: A patient with bipolar disorder is experiencing a manic episode. What is
the priority nursing action?
A: Ensure safety by minimizing stimulation and providing a structured environment.
6. Q: What is a key teaching point for a patient starting benzodiazepines for
anxiety?
,A: Avoid alcohol and operating heavy machinery due to sedation and risk of dependence.
7. Q: How should a nurse respond to a patient expressing suicidal ideation with a
plan?
A: Implement immediate safety precautions, notify the provider, and provide one-to-one
supervision.
8. Q: Which medication is most appropriate for managing acute dystonia in a
patient receiving antipsychotics?
A: Diphenhydramine IM or benztropine IM.
9. Q: A patient with PTSD experiences flashbacks triggered by loud noises. What
intervention should the nurse prioritize?
A: Create a safe and calm environment and use grounding techniques.
10. Q: What is the most effective nonpharmacological intervention for a patient
with severe depression?
A: Structured psychotherapy such as CBT or interpersonal therapy.
11. Q: A patient starting sertraline reports headaches and nausea. What is the best nursing
action?
A: Educate the patient that these side effects are common early in treatment and often resolve
within a few weeks.
Rationale: SSRIs frequently cause mild GI and headache symptoms at initiation; reassurance
and adherence are key before considering medication changes.
12. Q: A client with schizophrenia exhibits paranoid delusions. What is the most
therapeutic nurse response?
, A: “I don’t share your belief, but I’m here to support you.”
Rationale: Validating the client’s feelings without endorsing delusions maintains trust and
reality orientation.
13. Q: A patient on haloperidol develops a sudden stiff neck and severe muscle rigidity.
What should the nurse suspect?
A: Neuroleptic malignant syndrome (NMS).
Rationale: NMS is a rare but life-threatening reaction to antipsychotics marked by rigidity,
hyperthermia, and autonomic instability requiring emergency care.
14. Q: Which lab test should be routinely monitored for a patient on clozapine?
A: Complete blood count (CBC) with differential.
Rationale: Clozapine can cause agranulocytosis; frequent CBC monitoring is essential to detect
this early.
15. Q: A patient with depression is noncompliant with medication due to sexual side effects.
What is an appropriate nursing action?
A: Discuss possible medication alternatives and encourage open communication with the
prescriber.
Rationale: Sexual dysfunction is a common cause of SSRI nonadherence; addressing concerns
can improve compliance.
16. Q: What is the priority nursing intervention for a patient experiencing a panic attack?
A: Stay with the patient and encourage slow, deep breathing.
Rationale: Providing reassurance and helping control breathing reduces symptoms and prevents
escalation.
17. Q: What is an expected finding in a patient withdrawing from alcohol?
A: Tremors, diaphoresis, and agitation.
Rationale: These symptoms reflect CNS hyperexcitability during withdrawal and can escalate to
seizures if untreated.