ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 of 5
A client with dementia was admitted to a dementia unit after she began persistently wandering away from home. The nursing staff should plan to:
Correct Answer: D
Rationale: The correct answer is D because providing the client with an electronic alarm that sounds when she nears the exit door is the best option to ensure her safety. This approach allows for monitoring without restricting her movement excessively. Choice A is incorrect as unlimited freedom poses risks. Choice B is not practical or feasible long-term. Choice C is not person-centered and may lead to discomfort and agitation. The electronic alarm in choice D is the most effective and least intrusive method to prevent wandering while respecting the client's autonomy.
Question 2 of 5
Which goal has priority for a patient with anorexia nervosa undergoing nutritional stabilization?
Correct Answer: B
Rationale: The correct answer is B because ensuring the patient eats 100% of each meal served is crucial for nutritional rehabilitation in anorexia nervosa. This goal helps the patient meet their caloric needs and address malnutrition. It is essential to monitor and support the patient in consuming all the food provided to promote weight restoration and overall health. The other options are less critical: A focuses on timing rather than full intake, C involves choice rather than completion, and D emphasizes supervision but not necessarily full consumption.
Question 3 of 5
A 35-year-old woman is being assessed related to suspected battering. In interviewing this patient, it is important for the nurse to keep in mind that: (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because when assessing a patient related to suspected battering, the nurse should demonstrate concern and caring to establish trust and encourage the patient to open up. This approach helps build rapport and facilitates communication, leading to a more accurate assessment and better support for the patient. Choice B is incorrect because using professional terminology might intimidate the patient and hinder effective communication. Choice C is incorrect because documenting injuries without sensitivity and consideration for the patient's emotional well-being can further traumatize the individual. Choice D is incorrect as the nurse's demeanor and approach are crucial in addressing cases of suspected battering.
Question 4 of 5
A client, age 70, was brought into the Emergency Department by family members who reported a fall. During the assessment, the nurse became suspicious that the client had suffered physical abuse. The client denied that she had been abused. Her denial is most likely based on her:
Correct Answer: B
Rationale: The correct answer is B: Emotional response to the situation. The client's denial is likely due to emotional factors such as shame, embarrassment, or fear of causing trouble for family members. This emotional response can lead the client to deny abuse even when it has occurred. Choice A is incorrect because fear of retaliation may be a factor, but emotional response is more likely. Choice C is incorrect as cognitive impairment would affect the client's ability to understand and respond to the situation, not necessarily lead to denial. Choice D is incorrect as the client's denial is influenced by emotional factors.
Question 5 of 5
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:
Correct Answer: A
Rationale: The correct answer is A: Drug use. Given the client's sudden onset of symptoms, including altered mental status, agitation, memory impairment, delusions, and misinterpretations of surroundings, drug use is the most likely cause. Step 1: Consider the timeline - symptoms started within a few hours. Step 2: Review the symptoms - agitation, memory impairment, delusions, altered mental status. Step 3: Think of common causes for acute onset of these symptoms - drug use can lead to these manifestations. Step 4: Rule out other potential causes - infection and metabolic disorders typically present with different symptomatology and are less likely in this acute scenario. Step 5: Therefore, the nurse should prioritize assessing the client for drug use to provide appropriate interventions.