ATI RN
Target Healthcare 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 roommate states that the patient "was fine after getting up this morning but started talking crazy about 3 hours ago." The patient's cognitive impairment is most consistent with:
Correct Answer: A
Rationale: The correct answer is A: delirium. Delirium is an acute change in mental status characterized by fluctuating levels of consciousness, inattention, disorganized thinking, and altered perception. In this case, the patient's clouded and clear sensorium, agitation, and recent onset of symptoms are indicative of delirium. Choice B: dementia, is incorrect because dementia is a chronic, progressive decline in cognitive function that does not typically present with acute changes in mental status. Choice C: sundown syndrome, is incorrect as it refers to a pattern of worsening confusion or agitation in the late afternoon or evening, not necessarily characterized by acute onset and fluctuating levels of consciousness. Choice D: early-onset Alzheimer disease, is incorrect because Alzheimer's disease is a specific type of dementia that does not typically present with the acute and fluctuating symptoms described in the scenario.
Question 2 of 5
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin." Select the best initial nursing diagnosis.
Correct Answer: D
Rationale: The correct initial nursing diagnosis is D: Imbalanced nutrition: less than body requirements related to self-starvation. The patient's presentation of yellow skin, cold extremities, bradycardia, low weight, and refusal to eat indicate severe malnutrition due to self-starvation. The key indicators are the physical signs of malnutrition and the patient's statement about not eating until they lose enough weight. Options A and B do not address the primary issue of malnutrition and self-starvation. Option C focuses on coping skills, which is not the priority in this case. Therefore, option D is the best initial nursing diagnosis to address the patient's life-threatening condition of malnutrition.
Question 3 of 5
Which expectation should be considered most critical prior to discharging a client with anorexia nervosa from the hospital?
Correct Answer: A
Rationale: Rationale: A critical expectation before discharging a client with anorexia nervosa is the attainment of minimum normal weight. This is crucial for the client's physical health and to prevent complications like organ damage. Resuming a normal menstrual cycle (B) is important but not as critical as restoring weight. Knowing about nutrition (C) is valuable but not as urgent as weight gain. Reducing exercise (D) may be necessary, but weight restoration takes precedence for overall health.
Question 4 of 5
A client with anorexia nervosa engages in manipulative behavior. She tells the nurse, 'I can't get weighed this morning, because I drank a glass of juice a few minutes before breakfast.' The best approach by the nurse would be:
Correct Answer: D
Rationale: Step 1: The correct answer is D because it sets clear boundaries and enforces consistency by reminding the client of the established protocol. Step 2: By stating "This is weight day. Please step on the scale," the nurse maintains the structure and accountability in the treatment plan. Step 3: This response avoids reinforcing manipulative behavior and emphasizes the importance of following the agreed-upon rules for accurate monitoring. Step 4: Other choices like A may inadvertently validate the manipulation, B suggests giving in to the client's avoidance tactic, and C delays the weighing without addressing the manipulation directly.
Question 5 of 5
The nurse who works in a sleep clinic knows that approximately ______% of adults suffer from insomnia.
Correct Answer: B
Rationale: The correct answer is B (30 to 40%). Insomnia is a common sleep disorder, affecting around 30-40% of adults. This range reflects the prevalence rates reported in various studies. Choices A, C, and D are incorrect because they provide prevalence rates that are either too low (A) or too high (C, D) compared to the generally accepted range for insomnia in adults. It is essential for the nurse in a sleep clinic to understand the prevalence of insomnia accurately to provide appropriate care and support to patients.