ATI RN
Age Specific Care Questions
Question 1 of 5
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
Correct Answer: C
Rationale: The correct answer is C: Disturbed thought processes. The client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disturbance in thought processes. This nursing diagnosis focuses on the client's cognitive functioning and perception of reality. A: Risk for violence is not the most appropriate diagnosis in this case as there is no direct evidence of the client being a risk to herself or others. B: Defensive coping does not address the client's specific symptoms of delusions and disorganized thinking. D: Impaired memory is not the most appropriate diagnosis as the client's symptoms are more indicative of a broader disturbance in thought processes rather than just memory deficits. Therefore, choice C is the most suitable nursing diagnosis based on the client's presentation of delusional behavior and disorganized thoughts.
Question 2 of 5
An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. At this point, the risperidone medication would have had sufficient time to begin exerting its therapeutic effects on the individual's symptoms of hallucinations and delusions. It typically takes a few days for antipsychotic medications like risperidone to reach therapeutic levels in the body and start alleviating psychotic symptoms. By day 3, the individual may start to demonstrate improved trust in the nurse due to the reduction in distressing symptoms. Incorrect options: A: Day of admission - It is unlikely to see significant improvement in symptoms and trust on the same day of admission. C: Day 5 of hospitalization - By this time, the medication would have likely already started showing some effects, and the individual would have had some time to build trust with the nurse. D: Day 7 of hospitalization - Waiting until day 7 might be too late to note beginning trust and significant reduction in symptoms, as the
Question 3 of 5
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
Correct Answer: D
Rationale: The correct answer, D, is indicative of auditory hallucinations. Darting eyes may suggest that the patient is hearing voices, distracted behavior aligns with responding to internal stimuli, and mumbling to oneself could be a response to hearing voices. Choices A, B, and C do not directly relate to auditory hallucinations, as they are more indicative of other mental health symptoms such as social withdrawal, mania, anxiety, or compulsive behaviors. Selecting D helps identify potential auditory hallucinations based on observed behaviors associated with hearing voices.
Question 4 of 5
A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, 'It's beat, it's eat. No room for doom.' The nurse can correctly assess this verbalization as:
Correct Answer: B
Rationale: The correct answer is B: clanging. Clanging refers to the pattern of speech characterized by the association of words based on sound rather than meaning. In this case, the patient's verbalization, "It's beat, it's eat. No room for doom," demonstrates a connection based on rhyming sounds rather than coherent meaning. This is a classic example of clanging commonly seen in individuals with disorganized schizophrenia. Neologisms (choice A) refer to new words created by the individual, ideas of reference (choice C) involve believing that external events have special significance for oneself, and associative looseness (choice D) pertains to a lack of logical connection between thoughts. These choices are incorrect as they do not accurately describe the patient's speech pattern in this scenario.
Question 5 of 5
The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a patient with schizophrenia who demonstrates auditory hallucinations, apathy, anhedonia, and poor social functioning. The patient is overweight and has hypertension. Bearing these facts in mind, the drug the nurse should advocate would be:
Correct Answer: D
Rationale: The correct answer is D: aripiprazole (Abilify). Aripiprazole is a second-generation antipsychotic that is less likely to cause weight gain and metabolic side effects compared to other antipsychotics. This is important since the patient is already overweight and has hypertension. Aripiprazole also has a lower risk of causing sedation, which can be beneficial for addressing apathy and anhedonia without worsening social functioning. A: Clozapine is effective for treatment-resistant schizophrenia but is associated with significant weight gain and metabolic side effects. B: Haloperidol is a first-generation antipsychotic with a high risk of extrapyramidal side effects and is not ideal for a patient with hypertension. C: Olanzapine is known for causing significant weight gain and metabolic effects, making it a less suitable choice for an overweight patient with hypertension.