ATI RN
Age Specific Care Questions
Question 1 of 5
A child, age 9, is being evaluated in the Emergency Department at the hospital. Her mother reports that the child fell down the stairs in her home. Her mother is with her and describes her as a 'clumsy kid.' The nurse practitioner suspects child abuse. Which of these findings indicates that physical abuse may be a chronic problem for the child?
Correct Answer: B
Rationale: The correct answer is B - Unhealed fractures revealed on x-ray. This finding indicates chronic physical abuse as unhealed fractures suggest repeated trauma over time. This is concerning because chronic abuse can lead to severe physical and emotional consequences for the child. A: Bloody nose and blackened eyes may indicate acute physical abuse, but not necessarily chronic abuse. C: Clinging to her mother as she attempted to leave is a behavior often seen in children who are anxious or scared in a medical setting, but it does not specifically indicate chronic physical abuse. D: Struggling with the staff that attempts to obtain a blood specimen could be a response to fear or discomfort with medical procedures, which does not definitively point to chronic abuse.
Question 2 of 5
A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacantly. You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
Correct Answer: C
Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication. Rationale: 1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances. 2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion. 3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself. Summary: A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem. B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario. D: Disturbed body image, anxiety, pain - Disturbed
Question 3 of 5
A client has been diagnosed with Alzheimer's disease, stage 1. The nurse would expect to help the family plan measures to assist the client with:
Correct Answer: A
Rationale: The correct answer is A: Recent memory loss. In stage 1 of Alzheimer's disease, the primary symptom is mild memory loss, particularly with recent events and information. The nurse would help the family plan measures to assist the client by implementing strategies to support memory, such as setting reminders, organizing daily routines, and using memory aids. Choice B, catastrophic reactions, is more commonly associated with later stages of the disease. Choice C, progressive gait disturbances, is not a typical symptom of stage 1 Alzheimer's. Choice D, perseveration, involves the repetition of a particular response or behavior and is not a primary concern in stage 1 Alzheimer's disease.
Question 4 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 5 of 5
The elderly spouse of a female Alzheimer's client states that his wife seems to wander aimlessly from room to room looking for things in incorrect places, such as kitchen utensils in the bedroom and laundry detergent in the kitchen. He asks the nurse for suggestions of what he can do to help her. What is the nurse's best response?
Correct Answer: D
Rationale: The correct answer is D: Place large signs on doors or entryways that identify the room. This is the best response because it directly addresses the issue of the client's confusion and disorientation by providing clear visual cues to help her navigate the home environment effectively. By labeling the rooms with large signs, the client can easily recognize where she is and find what she needs. This strategy helps reduce her anxiety and frustration, promoting a sense of independence and safety. Choices A, B, and C are incorrect because they do not specifically target the client's cognitive challenges related to Alzheimer's disease. Keeping rooms well lit, having a simple environment, and using clocks with large letters are helpful suggestions but do not address the primary issue of the client's spatial disorientation and confusion. Placing large signs on doors directly addresses the client's specific needs and is the most effective strategy in this situation.