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. He 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 nurse would assess 'frobitz' as:
Correct Answer: D
Rationale: The correct answer is D: A neologism. A neologism is a newly coined word or expression that is not easily understood by others. In this case, the client's use of the word 'frobitz' is not a recognized word, indicating it may be a neologism. This is commonly seen in individuals with schizophrenia who create new words or distort existing ones. A: Circumstantial speech involves excessive and unnecessary details before reaching the main point. The client's response is not characterized by this. B: Loose associations involve a lack of logical connections between thoughts. The client's response is not demonstrating this. C: Evidence of delusional thinking would involve fixed, false beliefs that are not based in reality. The client's use of 'frobitz' does not necessarily indicate a delusion. In summary, the use of 'frobitz' by the client is indicative of a neologism, as it is a new and potentially meaningless
Question 2 of 5
The nurse is assessing a client who will be having an orthopedic surgery. The client takes an antipsychotic medication and shares that he has recently started using two herbal preparations for his nerves. The nurse should:
Correct Answer: A
Rationale: Rationale: A: Asking for the specific names of the herbal compounds is important to assess potential interactions with the antipsychotic medication. B: Ignoring the herbal compounds could lead to adverse effects or interactions during surgery. C: Telling him to stop may not be appropriate without knowing the specific compounds and their effects. D: Discussing the physician's viewpoint is not as crucial as gathering information on potential interactions.
Question 3 of 5
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale. 1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine. 2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia. 3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia. 4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described. 5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned. 6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.
Question 4 of 5
A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.
Question 5 of 5
A severely withdrawn patient diagnosed with schizophrenia will spend time in the dayroom but will not speak to staff or to other patients. The most therapeutic nursing intervention in response to this behavior would be to:
Correct Answer: D
Rationale: The correct answer is D because it focuses on building a therapeutic relationship with the patient without placing pressure on them to speak. By planning time for staff members to sit with the patient, even if the patient does not talk, it allows for nonverbal communication and presence to convey support and care. This approach respects the patient's boundaries and allows them to engage at their own pace, fostering trust and a sense of safety. Choice A is incorrect as it may overwhelm the patient by placing them in a social situation they are not ready for. Choice B is incorrect as discussing superficial topics does not address the patient's underlying issues. Choice C is incorrect as it may make the patient feel judged or pressured to speak, further isolating them.