ATI RN
Age Specific Nursing Care 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. The client's symptoms of disorganized thinking, difficult-to-follow speech, inappropriate affect, social withdrawal, and hallucinations (responding to unseen stimuli) align with the diagnostic criteria for Disorganized Schizophrenia. This subtype is characterized by disorganized behavior, speech, and affect, as well as social withdrawal and hallucinations. A: Residual schizophrenia does not involve active psychotic symptoms like hallucinations or delusions, which are present in the client's behavior described. B: Schizoaffective disorder combines symptoms of schizophrenia and mood disorders, and the client's symptoms do not strongly suggest a mood disorder component. C: Paranoid schizophrenia typically involves prominent delusions and auditory hallucinations, which are not emphasized in the client's behavior described.
Question 2 of 5
A client with schizophrenia tells the nurse as they sit in the day room, 'I hear voices telling me bad things.' The most therapeutic response the nurse can make is:
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation of the client's experience. By acknowledging the client's reality of hearing voices and emphasizing that the nurse does not hear them, the nurse establishes trust and rapport. This response shows active listening and validates the client's feelings without judgment. Incorrect responses: A: Asking the client to describe the voices may increase distress and is not as supportive as acknowledging their experience. C: Dismissing the voices as not real can invalidate the client's experience and may lead to mistrust. D: Suggesting a change of location does not address the client's immediate concerns and may not be therapeutic in this situation.
Question 3 of 5
Police bring a 63-year-old woman to the emergency room, reporting that her behavior is disorganized and disruptive, that her speech makes little sense, and that she does not seem able to take care of herself. The woman has had elective surgeries at the hospital previously and was seen in the ER last week after a fall; records show no history of similar symptoms or mental illness. The ER physician speaks with the patient but does not examine her medically, diagnoses her with schizophrenia, and orders admission to the inpatient psychiatric unit. Which response by the nurse would be most appropriate?
Correct Answer: C
Rationale: The correct answer is C because it promotes a thorough and systematic approach to the patient's care. First, it challenges the premature diagnosis of schizophrenia without a medical examination. Second, it highlights the importance of considering medical causes for the symptoms presented by the patient. This is crucial as the patient's age and lack of prior history of mental illness suggest that a medical work-up is necessary to rule out underlying medical conditions that could be causing her symptoms. This approach ensures a comprehensive evaluation and appropriate treatment tailored to the patient's specific needs. Choices A, B, and D are incorrect because they do not address the fundamental issue of exploring potential medical causes for the patient's symptoms before jumping to a psychiatric diagnosis or treatment. A, B, and D focus on seeking additional psychiatric opinions, consulting for medication initiation, and evaluating vital signs, respectively, which do not address the need for a thorough medical evaluation in this case.
Question 4 of 5
The family of a patient with schizophrenia who has been stable for a year reports to the community mental health nurse that the patient reports feeling tense and having difficulty concentrating. He sleeps only 3 to 4 hours nightly and has begun to talk about creatures called 'volmers' hiding in the warehouse where he works and undoing his work each night. This information most likely suggests:
Correct Answer: D
Rationale: The correct answer is D: relapse of his schizophrenia. The patient is displaying symptoms such as feeling tense, difficulty concentrating, disturbed sleep, and delusional thoughts about creatures hiding in his workplace. These symptoms indicate a return of psychotic features characteristic of schizophrenia, suggesting a relapse. This is supported by the patient's history of schizophrenia and the sudden onset of symptoms after a period of stability. Medication nonadherence (choice A) could be a possible cause, but the patient's symptoms are more indicative of a relapse. While psychoeducation (choice B) is important, the patient's current symptoms require immediate attention for relapse management. The chronic nature of his illness (choice C) is a general characteristic of schizophrenia and does not explain the current symptoms.
Question 5 of 5
A young patient diagnosed with schizophrenia is standing naked after showering and appears to be both dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
Correct Answer: B
Rationale: The correct answer is B. By saying, "These are your underpants. I'll help you put them on," the nurse provides clear guidance and offers assistance, which can help the patient feel more comfortable and supported in the dressing process. This approach acknowledges the patient's need for help while respecting their autonomy. Choice A is too directive and may make the patient feel pressured or overwhelmed. Choice C involves too many options, which can be confusing for a patient experiencing indecisiveness. Choice D assumes a problem with the clothes rather than focusing on the patient's needs and feelings. Overall, choice B is the most appropriate and supportive intervention in this situation.