A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:

Questions 29

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ATI RN Test Bank

Kaplan and Sadocks Synopsis of Psychiatry Test Bank Questions

Question 1 of 9

A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:

Correct Answer: D

Rationale: The correct answer is D because volunteering at the local homeless shelter fulfills the self-actualization need in Maslow's hierarchy. By helping others and contributing to the community, the patient gains a sense of purpose and fulfillment, boosting self-esteem. A: Moving to a secure apartment building addresses safety needs, not self-esteem. B: Exercising with friends promotes social belonging but does not directly address self-esteem. C: Attending grandchildren's functions fosters social connections, but it may not directly impact self-esteem like volunteering does.

Question 2 of 9

The desired outcome for a patient experiencing insomnia is, "Patient will sleep for a minimum of 5 hours nightly within 7 days." At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. The nurse will document the outcome as:

Correct Answer: C

Rationale: The correct answer is C: Sometimes demonstrated. The rationale is that the patient is not consistently meeting the desired outcome of sleeping for a minimum of 5 hours nightly within 7 days. Although the patient is sleeping for an average of 4 hours nightly, the 2-hour afternoon nap indicates that the patient is not achieving the desired outcome consistently. Therefore, the nurse would document the outcome as "Sometimes demonstrated" to reflect that the patient is making progress towards the goal but has not fully achieved it. Choices A, B, and D are incorrect because the patient's sleep behavior does not align with being consistently, often, or never demonstrated based on the desired outcome criteria.

Question 3 of 9

A patient asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply, A durable power of attorney for health care:

Correct Answer: A

Rationale: Correct Answer: A: Gives your agent authority to make decisions during any illness if you are incapacitated. Rationale: 1. A durable power of attorney for health care allows you to appoint a trusted individual (agent) to make medical decisions on your behalf if you are unable to do so. 2. This authority is not limited to a specific type of illness or condition, ensuring your agent can make decisions for any illness that renders you incapacitated. 3. This flexibility ensures that your wishes are carried out regardless of the circumstances. Summary of Other Choices: B: Incorrect - A durable power of attorney can be given to any trusted individual, not just a relative. C: Incorrect - A durable power of attorney can be used in any situation where you are unable to make decisions, not just in terminal illness. D: Incorrect - A durable power of attorney can be implemented immediately upon signing, providing timely decision-making support.

Question 4 of 9

The Omnibus Budget Reconciliation Act (OBRA) provides standards of care for which of the following?

Correct Answer: B

Rationale: The correct answer is B: Older adults. OBRA primarily focuses on setting standards of care for older adults in long-term care facilities, ensuring their safety and well-being. This is because older adults are a vulnerable population requiring specialized care and attention. Choices A, C, and D are incorrect because OBRA does not specifically address very young individuals, those with intellectual communication difficulties, or individuals without medical insurance. The Act mainly pertains to the care and rights of older adults in long-term care settings.

Question 5 of 9

During the first family therapy session, the mother of a child being treated for truancy and emotional outbursts asks the nurse, “Why are you bothering to ask the rest of us questions? My son is the one with the problems.” The best response for the nurse would be:

Correct Answer: A

Rationale: The correct answer is A because involving the entire family in therapy sessions allows for a more comprehensive understanding of the family dynamics and how they may be contributing to the child's issues. By including all family members, the nurse can gather diverse perspectives and insights that can inform the treatment plan. This approach also promotes family unity and collaboration in addressing the child's problems. Option B is not the best response as it lacks a clear rationale for involving the whole family. Option C, while partially true, does not directly address the question raised by the mother. Option D emphasizes the importance of every family member's perceptions but does not specifically address the benefits of involving the entire family in therapy sessions.

Question 6 of 9

Which intervention would qualify as primary prevention of violent behaviors in children and adolescents?

Correct Answer: B

Rationale: The correct answer is B because limiting exposure to violence on TV, video, and computer games falls under primary prevention by addressing risk factors before violent behaviors occur. This intervention helps reduce the likelihood of children and adolescents developing violent tendencies by minimizing their exposure to violent content that can influence their behavior. A: Forbidding the child to continue friendships with violent peers is more of a secondary prevention strategy targeting existing risk factors, not primary prevention. C: Seeking counseling for a child who has been experimenting with drugs is also a secondary prevention strategy focusing on addressing a specific risk factor, not primary prevention. D: Showing a unified approach to parenting when dealing with a violent child is a tertiary prevention strategy aimed at managing and reducing harm after the behavior has already occurred, not primary prevention.

Question 7 of 9

How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group?

Correct Answer: A

Rationale: The correct answer is A because offering to dance with the patient shows support, builds trust, and models behavior. This approach can help the shy patient feel more comfortable and encouraged to participate. Choice B focuses on the patient's past experience, which may not directly address the current issue. Choice C isolates the patient, potentially increasing feelings of shyness. Choice D involves a third party, which may not be as effective in building a direct connection with the shy patient. Overall, option A is the most effective in directly engaging and encouraging the shy patient to participate therapeutically in the dance activity group.

Question 8 of 9

Which activities should the nurse evaluate in an assessment of an older patient’s functional status? (Select all that apply.)

Correct Answer: A,C

Rationale: The correct answers are A and C. A nurse should evaluate if the older patient can prepare nutritious meals independently, as this indicates their ability to meet basic nutritional needs and maintain independence in daily living. Additionally, assessing if the patient can perform regular, simple maintenance on their primary residence is important for gauging their ability to live safely and comfortably. Choices B and D are incorrect as financial resources and toileting abilities, while important, do not directly reflect functional status in the same way as meal preparation and home maintenance.

Question 9 of 9

The nurse counseling a patient with acute grief would assess the patient for:

Correct Answer: B

Rationale: The correct answer is B because acute grief typically involves conflicting and unresolved emotions and thoughts related to the loss. The nurse would assess for unresolved issues to provide appropriate support and interventions. Choice A is incorrect as severe depressive symptoms may indicate complicated grief, not typical acute grief. Choice C is incorrect as increased arousal and hypervigilance are more characteristic of post-traumatic stress disorder. Choice D is incorrect as preoccupation with the image of the deceased may be a common experience in grief but does not encompass the full range of emotions and conflicts that acute grief entails.

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