ATI RN
Age Specific Care Questions
Question 1 of 5
A 75-year-old male client is brought to the clinic by his son. The son states, 'Ever since Mom died, Dad hasn't been the same. At first he just seemed sad, but now he seems to get mixed up about everything.' The nurse is aware that based on the client's history, the source of confusion is most likely:
Correct Answer: B
Rationale: Correct Answer: B - Depression from the loss of his wife Rationale: Given the client's recent loss of his wife and subsequent changes in behavior, the most likely cause of his confusion is depression. Depression can manifest as cognitive impairment in older adults, leading to symptoms such as confusion and memory problems. Additionally, grief and loss can exacerbate depressive symptoms in elderly individuals, further contributing to cognitive difficulties. Summary of other choices: A: Dementia - Dementia typically presents with gradual cognitive decline over time, not a sudden onset following a specific event like the loss of a loved one. C: Hypoxia of the brain - Hypoxia would likely present with more acute symptoms and physical signs, such as shortness of breath or cyanosis. D: Delirium from medications - Delirium is characterized by acute onset and fluctuating course, often related to medication changes or other medical conditions, rather than an emotional trigger like grief.
Question 2 of 5
Which of the following assessments is most appropriate for a patient with anorexia nervosa?
Correct Answer: C
Rationale: The correct answer is C because observing the patient's response to meals, including food refusal or purging behavior, is crucial in assessing the patient's eating habits and behaviors associated with anorexia nervosa. This assessment helps in understanding the patient's relationship with food and identifying any disordered eating patterns. Monitoring fluid intake exclusively (Choice A) is not sufficient as it overlooks the broader aspects of the patient's eating behaviors. Checking weight daily without discussing it with the patient (Choice B) can be triggering and may not provide a comprehensive understanding of the patient's eating disorder. Monitoring for signs of vitamin and mineral deficiencies (Choice D) is important but does not directly address the specific behaviors associated with anorexia nervosa.
Question 3 of 5
A victim of a sexual assault sits in the emergency department rocking back and forth. This behavior is characteristic of:
Correct Answer: A
Rationale: The correct answer is A: The acute phase reaction. This behavior is common in the immediate aftermath of a traumatic event like sexual assault. The victim may exhibit physical and emotional symptoms such as rocking back and forth, confusion, disorientation, and numbness. This reaction is a natural response to the overwhelming stress and trauma experienced. Choice B, the angry stage of rape, is incorrect as it does not capture the immediate post-assault response. Choice C, trauma syndrome, is too vague and does not specifically address the behavior described. Choice D, None of the above, is incorrect as the victim's behavior aligns with the acute phase reaction typically seen in trauma survivors.
Question 4 of 5
A client seen by the rape crisis nurse 1 month after the incident states, 'I'm confused and just not myself. I have mood swings during the day, and I have nightmares at night. Sometimes I think I'm going crazy.' Other times, she is just plain afraid to be alone. The nurse should assess the client for:
Correct Answer: A
Rationale: The correct answer is A: Trauma syndrome. This choice is correct because the client's symptoms of confusion, mood swings, nightmares, feeling like they are going crazy, and fear of being alone align with the criteria for trauma syndrome. This syndrome encompasses a range of symptoms that occur after experiencing a traumatic event, such as rape. Choice B: Post-traumatic stress disorder (PTSD) is not the best option in this case because the client's symptoms are more indicative of acute distress and confusion rather than the criteria for a formal diagnosis of PTSD, which typically requires the persistence of symptoms over time. Choice C: Acute stress disorder is also not the most appropriate choice because while some symptoms may align, the duration and specific criteria for this disorder may not fully match the client's presentation. Choice D: None of the above is incorrect as trauma syndrome best fits the client's symptoms based on the information provided.
Question 5 of 5
A patient with fluctuating levels of awareness, confusion, and disorientation shouts, 'The bugs, they are crawling on my legs! Get them off me!' The nurse's inspections show that no bugs are present. The nurse can best assess this presentation as:
Correct Answer: C
Rationale: The correct answer is C: Tactile hallucinations. Tactile hallucinations involve the perception of physical sensations such as bugs crawling on the skin when no external stimuli are present. In this scenario, the patient's complaint of bugs crawling on their legs despite the nurse's inspection confirming the absence of bugs indicates a sensory hallucination, specifically a tactile one. This is different from perseveration (repetition of a particular response or activity) and hypermetamorphosis (excessive attention to environmental details). Choosing "None of the above" would not address the specific symptom of tactile hallucinations described in the patient's presentation.