ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 of 5
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. The client occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The best response for the nurse to make would be:
Correct Answer: B
Rationale: The correct answer is B: "Who do you mean when you say 'everybody'?" Rationale: 1. Clarifying the client's statement helps to understand his perception. 2. Asking specifically about 'everybody' encourages the client to express his feelings and thoughts. 3. It promotes therapeutic communication by showing empathy and active listening. Incorrect choices: A: "That's really too bad." - This response does not address the client's specific concerns or promote further exploration. C: "What difference does frobitzing make?" - This response is dismissive and lacks empathy or understanding of the client's experience. D: "Why do they frobitz?" - This response is confrontational and may come across as accusatory, potentially shutting down communication.
Question 2 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's symptoms of feeling tense, difficulty concentrating, poor sleep, and delusional beliefs about creatures at work indicate a worsening of his psychotic symptoms. This suggests a relapse of schizophrenia, a chronic mental illness characterized by periods of stability and exacerbation of symptoms. The patient's previous stability for a year makes medication nonadherence less likely. While psychoeducation may be beneficial, the patient's current symptoms require more immediate intervention for relapse management. The information provided does not directly indicate the chronic nature of his illness, but rather an acute exacerbation. Therefore, D is the most appropriate choice based on the presented symptoms and clinical understanding of schizophrenia.
Question 3 of 5
An 82-year-old widow with Alzheimer's disease lives with her daughter's family, which owns a catering business. During the week, the patient attends a day care center for patients with dementia. During the evenings, members of the family care for the patient. One day, the nurse at the day care center notices the patient's appearance is disheveled and that she startles easily. She has a strong odor of urine, and her hair is uncombed. When the nurse escorts the patient to the bathroom, she notices bruises on her wrists and back. What most likely explains the nurse's observations?
Correct Answer: A
Rationale: The correct answer is A: The patient is being neglected and abused within the family. The nurse's observations of the patient's disheveled appearance, strong odor of urine, uncombed hair, and bruises indicate signs of neglect and abuse. Here's the rationale: 1. Disheveled appearance and strong odor of urine suggest lack of personal care. 2. Uncombed hair signals neglect in grooming. 3. Bruises on wrists and back are indicative of physical abuse. 4. Startling easily may be due to fear or anxiety from abuse. In summary, the other choices (B, C, D) are incorrect because they do not account for the combination of neglect, poor hygiene, and physical injuries seen in the patient, which are more indicative of abuse and neglect within the family.
Question 4 of 5
After a person was abducted and raped at gunpoint by an unknown assailant, which assessment finding best indicates the acute phase of the rape-trauma syndrome?
Correct Answer: B
Rationale: The correct answer is B: Confusion and disbelief. During the acute phase of rape-trauma syndrome, the victim may experience feelings of confusion and disbelief as they try to process the traumatic event. This initial reaction is a common response to such a severe and violating experience. The victim may struggle to comprehend what has happened to them, leading to feelings of shock and disbelief. This phase is characterized by emotional numbing, disorientation, and difficulty in making decisions. Decreased motor activity (Choice A) is not specific to the acute phase of rape-trauma syndrome and can be a general response to trauma. Flashbacks and dreams (Choice C) are more commonly associated with the intrusion phase of the syndrome, which occurs after the acute phase. Fears and phobias (Choice D) may develop later in the reorganization phase of the syndrome as the victim tries to cope with the aftermath of the trauma.
Question 5 of 5
A victim of a sexual assault sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of:
Correct Answer: A
Rationale: The correct answer is A: The acute phase reaction. This behavior is characteristic of the immediate emotional response following a traumatic event like sexual assault. The victim may exhibit shock, disbelief, and emotional distress. In this scenario, the victim's reaction of disbelief and repetitive statements align with the acute phase reaction. The other options are incorrect because the angry stage (B) and delayed reaction (C) occur later in the trauma response process, while the long-term phase (D) reflects a more prolonged period of adjustment and coping.