ATI RN
Theories of Health Behavior Change Questions
Question 1 of 5
A client tells a nurse, "Everyone would be better off if I wasn't alive." Which nursing diagnosis would be made based on this statement?
Correct Answer: C
Rationale: The correct answer is C: Risk for self-directed violence. The client's statement indicates suicidal ideation, which poses a risk for self-harm. This diagnosis focuses on the potential for the client to harm themselves. Disturbed thought processes (A) may be present, but the primary concern is the risk of self-directed violence. Ineffective coping (B) may contribute to the client's distress, but the immediate concern is the risk of harm to themselves. Impaired social interaction (D) is not the most relevant diagnosis in this scenario, as the client's statement is more indicative of self-harm than social interaction issues.
Question 2 of 5
A client taking the monoamine oxidase inhibitor (MAOI) antidepressant isocarboxazid (Marplan) is instructed by the nurse to avoid which foods and beverages?
Correct Answer: A
Rationale: The correct answer is A: Aged cheese and red wine. Isocarboxazid is an MAOI, which can interact with tyramine-rich foods like aged cheese and red wine, leading to hypertensive crisis. Other choices like milk, green leafy vegetables, carbonated beverages, tomato products, lean red meats, and fruit juices do not have the same potential for interaction with MAOIs. It's crucial for the client to avoid these foods and beverages to prevent serious adverse reactions.
Question 3 of 5
The doctor has prescribed haloperidol (Haldol) 2.5 mg. I.M. for an agitated client. The medication is labeled haloperidol 10 mg/2 ml. The nurse prepares the correct dose by drawing up how many milliliters in the syringe?
Correct Answer: C
Rationale: To calculate the correct dose: 1. Determine the desired dose: 2.5 mg 2. Determine the concentration of the medication: 10 mg/2 ml 3. Set up a proportion: 2.5 mg is to x ml as 10 mg is to 2 ml 4. Cross multiply: 2.5x = 10 * 2 5. Solve for x: 2.5x = 20 6. x = 20 / 2.5 = 8 ml Thus, the nurse should draw up 0.5 ml in the syringe, as it is the correct dose for the agitated client. Other choices are incorrect as they do not match the calculated dose based on the prescription and medication concentration.
Question 4 of 5
The nurse collecting family assessment data asks, 'Who is in your family and where do they live?' Which of the following is the nurse attempting to identify?
Correct Answer: A
Rationale: The nurse is attempting to identify family boundaries by asking about who is in the family and where they live. Boundaries define who is considered part of the family system and their physical proximity. This information helps the nurse understand the structure and dynamics of the family. Ethnicity (B), relationships (C), and triangles (D) are not directly related to the specific information being gathered here. Ethnicity pertains to cultural background, relationships refer to the connections within the family, and triangles are a concept in family systems theory involving three people. Therefore, the correct answer is A as it aligns with the purpose of the question in identifying family boundaries.
Question 5 of 5
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, "You are incompetent!" Which is the nurse's best response?
Correct Answer: B
Rationale: The correct answer is B: "I see that you are upset, but I feel uncomfortable when you swear at me." This response acknowledges the client's emotion, sets a boundary against inappropriate behavior, and expresses the nurse's discomfort without being confrontational. It maintains a professional and therapeutic communication while addressing the client's behavior. Choice A: "Do you believe that I was the cause of your blood test being canceled?" This response can come off as defensive and may escalate the situation by questioning the client's perception. Choice C: "Have you ever thought about ways to express anger appropriately?" This response may be perceived as patronizing or dismissive of the client's feelings, potentially leading to further frustration. Choice D: "I'll give you some space. Let me know if you need anything." While giving space can be helpful, this response does not directly address the client's inappropriate behavior or set boundaries, missing an opportunity to address the behavior constructively.