ATI RN
Target Healthcare Questions
Question 1 of 5
A client displays disorganized thinking, difficult-to-follow speech, and silly, inappropriate affect. The client isolates himself from other clients and staff, ignores unit activities, and often seems to be listening and responding to unseen stimuli. This client's behavior most closely conforms to the characteristic behavior of:
Correct Answer: D
Rationale: The correct answer is D: Disorganized schizophrenia. This client's presentation aligns with the symptoms of disorganized schizophrenia, characterized by disorganized thinking, speech, and behavior, inappropriate affect, social withdrawal, and hallucinations. Residual schizophrenia (A) refers to a milder form of schizophrenia with lingering symptoms. Schizoaffective disorder (B) involves symptoms of both schizophrenia and mood disorders. Paranoid schizophrenia (C) is characterized by delusions and auditory hallucinations, which are not the primary symptoms displayed by the client in the question.
Question 2 of 5
The physician prescribes haloperidol (Haldol), a first-generation antipsychotic drug, for a patient with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should most be monitored to evaluate the expected improvement from this medication?
Correct Answer: A
Rationale: The correct answer is A because haloperidol is primarily used to target positive symptoms of schizophrenia such as delusions and hallucinations. Monitoring improvements in symptoms like talking to himself and belief that others will harm him will indicate the effectiveness of the medication. Choices B, C, and D are incorrect because they focus on negative symptoms or general social withdrawal, which are less likely to show significant improvement with haloperidol, a first-generation antipsychotic drug that is more effective for positive symptoms. Monitoring these symptoms may not directly reflect the medication's effectiveness in treating the primary symptoms of schizophrenia in this case.
Question 3 of 5
A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. The patient's symptoms indicate a lack of ability to perform self-care activities, which poses a risk to their health and well-being. This is a priority as addressing this issue will directly impact the patient's physical health and overall functioning. Situational low self-esteem (B) is not the priority as it focuses on the patient's emotional state rather than their immediate physical needs. Disturbed thought processes (C) and impaired verbal communication (D) may be present but are not the priority over the patient's inability to perform self-care activities.
Question 4 of 5
A patient, aged 77 years, has Alzheimer's disease and lives with her daughter. While checking her blood pressure at the clinic, the nurse noticed fresh bruises on the patient's palms and buttocks. The patient could not explain these bruises. The nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage. She stated, "My mother is getting worse every week. She is not my mother anymore. She can't recognize me, and she wanders all night. We take turns because she has to be watched constantly. Last night I fell asleep, and she fell down the stairs while wandering." Which statement is most accurate?
Correct Answer: A
Rationale: Step 1: The nurse observed bruises on the patient's palms and buttocks. Step 2: The patient could not explain these bruises. Step 3: The daughter mentioned the patient's worsening condition and the incident of falling down the stairs. Step 4: The daughter's statement indicates the patient's deteriorating cognitive and physical abilities. Step 5: The daughter's challenges in managing the patient are due to the progression of Alzheimer's disease. Step 6: There is no explicit evidence or indication of elder abuse based on the provided information. Step 7: Reporting the injuries without clear signs of abuse may harm the patient's relationship with the daughter. Step 8: Therefore, the most appropriate action is not to report the injuries based on the available data to avoid potential harm. Summary: - Choice A is correct as reporting the injuries is not indicated by the available data. - Choices B, C, and D are incorrect as there is no clear evidence of elder abuse in the scenario
Question 5 of 5
A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me." The nurse should:
Correct Answer: B
Rationale: The correct answer is B: Explain that bathing would destroy evidence. This is the correct choice because bathing can potentially wash away crucial forensic evidence that can be collected during a sexual assault examination. Preserving evidence is essential for legal proceedings and ensuring justice for the victim. Choice A is incorrect because arranging for the patient to shower would destroy evidence. Choice C is incorrect as giving the patient a basin of water and towels would still risk destroying evidence. Choice D is also incorrect as it does not address the importance of preserving evidence in cases of sexual assault.