ATI RN
Age Specific Patient Care Questions
Question 1 of 5
A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's cognitive impairment is most consistent with:
Correct Answer: A
Rationale: The correct answer is A: Delirium. Delirium is characterized by acute onset, fluctuating course, altered level of consciousness, and cognitive impairment. In this case, the patient's alternating sensorium and agitation suggest an acute confusional state, which is typical of delirium. Delirium is often caused by underlying medical conditions, medications, or substance abuse. Summary of other choices: B: Dementia is a chronic, progressive cognitive decline that does not typically present with acute onset and fluctuating symptoms like delirium. C: Sundown syndrome refers to worsening of symptoms in the evening and is often seen in patients with dementia, not in this acute and fluctuating presentation. D: Early-onset Alzheimer's disease is a form of dementia that typically has a more insidious onset and does not present with acute fluctuations in cognition like delirium.
Question 2 of 5
The nurse is interviewing a client who presents with a dislocated shoulder. She demonstrates signs of anxiety and poor eye contact and turns to her partner for answers, allowing him to speak for her. The nurse asks the partner to go to the admitting office to give insurance information. While the partner is out of the room, which question is most important to ask?
Correct Answer: A
Rationale: Step 1: By asking how the shoulder dislocation occurred, the nurse can assess the mechanism of injury and potential risk factors for further harm. Step 2: Understanding the cause can guide treatment decisions and prevent future injuries. Step 3: This question is crucial for providing appropriate care and ensuring the client's safety. Summary: Option A is the correct answer as it directly relates to the client's current condition and allows the nurse to gather essential information for effective care. Options B and C are not as pertinent at this moment, and option D is incorrect as gathering information from the client is essential in this situation.
Question 3 of 5
The nurse is aware, when developing a care plan, that the three major goals of care for the client in whom Alzheimer's disease has been diagnosed include providing for the client's safety and well-being, therapeutically managing the client's behaviors, and:
Correct Answer: B
Rationale: The correct answer is B. Providing support for family, relatives, and caregivers is crucial in the care of a client with Alzheimer's disease as it helps to ensure a holistic approach to care. Family members and caregivers often experience significant stress and burden in caring for someone with Alzheimer's, so providing support to them can improve the overall quality of care for the client. Additionally, involving family and caregivers in the care plan can help in maintaining continuity and consistency in the client's care. Other choices are incorrect because: A: Supporting the client during curative care is not applicable in Alzheimer's disease as there is currently no cure for the condition. C: Arranging for nursing home placement may be necessary in some cases, but it is not one of the three major goals of care for a client with Alzheimer's disease. D: None of the above is incorrect as providing support for family, relatives, and caregivers is a critical aspect of care for clients with Alzheimer's disease.
Question 4 of 5
A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he found the woman confused and disoriented, with an unsteady gait. The patient asks him who he is and why he is there. The nurse correctly deduces that the most likely cause for the changes seen in the patient is:
Correct Answer: A
Rationale: The correct answer is A: Delirium. The patient's sudden onset of confusion, disorientation, and unsteady gait after discharge from the hospital suggests delirium. Delirium is an acute change in mental status with fluctuating symptoms, often caused by underlying medical conditions, medications (such as diazepam), or environmental factors. In this case, the recent hospitalization, multiple medications, and potential stressors like living alone and recent fall increase the risk for delirium. Incorrect choices: B: Dementia is a chronic, progressive condition characterized by memory loss and cognitive decline. The sudden onset of symptoms in this case is not consistent with dementia. C: Drug toxicity could be a possibility given the patient's medication list, but delirium is a more likely explanation due to the acute onset of symptoms post-hospitalization. D: None of the above is incorrect because delirium is the most likely cause based on the patient's presentation and risk factors.
Question 5 of 5
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
Correct Answer: D
Rationale: Rationale: 1. Patient's diagnosis indicates coping issues, not anger expression or self-esteem. 2. Patient's coping mechanism involves overeating and vomiting, not diet. 3. Outcome should focus on coping skills improvement, not unrelated goals. 4. None of the choices address the root issue of coping with loneliness and isolation. 5. Thus, the correct answer is D, as none of the options directly address the patient's ineffective coping mechanism.