ATI RN
Target Healthcare Questions
Question 1 of 5
A client tried to gouge out his eye in response to auditory hallucinations commanding, 'If thine eye offend thee, pluck it out.' The nurse would analyze this behavior as indicating:
Correct Answer: A
Rationale: The correct answer is A: Impaired impulse control. This behavior shows a lack of control over impulsive actions, as the client acted immediately on the auditory hallucination without considering the consequences. Choice B is incorrect because anger management is not directly related here. Choice C, derealization, refers to feeling disconnected from reality, which is not evident in the scenario. Choice D, inappropriate affect, does not fit as the client's action is more about impulsivity than emotional expression. Ultimately, the client's behavior aligns most closely with impaired impulse control due to the immediate and extreme response to the auditory hallucination.
Question 2 of 5
A client tells the nurse, 'I hear people whispering about me. When I'm in the day room and they do that, I want to punch them.' The information the nurse should give to staff in report consists of which of the following?
Correct Answer: A
Rationale: The correct answer is A: "Treat this client matter-of-factly. Be direct; don't talk about him or others in his presence." This response is appropriate because it emphasizes the importance of respecting the client's privacy and dignity by not discussing him or others in his presence. By being direct and matter-of-fact, the nurse can establish trust and build a therapeutic relationship with the client. This approach also helps maintain boundaries and avoids escalating the situation. Choice B is incorrect because avoiding the client may lead to feelings of rejection and worsen his symptoms. Choice C is incorrect because using touch without the client's consent may be inappropriate and could escalate the situation. Choice D is incorrect because speaking softly does not address the underlying issue of the client feeling threatened by whispering.
Question 3 of 5
A newly admitted patient with schizophrenia approaches the unit nurse and says, 'The voices are bothering me. They are yelling and telling me stuff. They are really bad.' Which response by the nurse would be most appropriate?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and empathy, which can help establish trust and rapport with the patient. By saying, "I'll stay with you. Tell me what you are hearing," the nurse acknowledges the patient's distress and offers support. This response can help the patient feel heard and understood, which is crucial in managing symptoms of schizophrenia. Choice A is incorrect as it focuses more on the frequency rather than addressing the immediate distress. Choice B is incorrect as it assumes the patient has a plan to escape the voices, which may not be the case and can escalate the situation. Choice D is incorrect as it dismisses the patient's experience and suggests distraction rather than addressing the underlying issue.
Question 4 of 5
A patient with schizophrenia begins to talk about creatures called 'volmers' hiding in the warehouse where he works and undoing his work each night. The term 'volmers' most likely represents:
Correct Answer: A
Rationale: The correct answer is A: a neologism. In schizophrenia, patients often create new words (neologisms) that have no meaning outside of their delusional context. The term 'volmers' is a made-up word by the patient, indicating a loss of touch with reality. Clanging (B) is a speech pattern characterized by rhyming or punning words, not creating new words. Anhedonia (C) refers to the inability to experience pleasure, unrelated to creating new words. Alogia (D) is a decrease in speech or thought productivity, not related to inventing new words. In this case, the patient's use of 'volmers' is indicative of a neologism associated with schizophrenia.
Question 5 of 5
During occupational therapy a young patient diagnosed with schizophrenia sits staring at a piece of paper. Which response is most therapeutic at this time?
Correct Answer: D
Rationale: The correct answer is D because it provides a clear and simple directive that guides the patient on what to do next, promoting engagement in the therapeutic activity. By instructing the patient to rub the glue stick on the back of the paper, it helps redirect their focus and encourages participation in the task. Choice A is incorrect as it allows the patient to disengage from the activity, which does not promote therapeutic progress. Choice B assumes the patient is anxious without evidence and may not address the core issue. Choice C is incorrect as it may not be relevant to the patient's current state and may further confuse or frustrate them.