ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
A client with schizophrenia tells the nurse as they sit in the day room, 'I hear voices telling me bad things.' The most therapeutic response the nurse can make is:
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and validation of the client's experience. By acknowledging the client's reality of hearing voices and emphasizing that the nurse does not hear them, the nurse establishes trust and rapport. This response shows active listening and validates the client's feelings without judgment. Incorrect responses: A: Asking the client to describe the voices may increase distress and is not as supportive as acknowledging their experience. C: Dismissing the voices as not real can invalidate the client's experience and may lead to mistrust. D: Suggesting a change of location does not address the client's immediate concerns and may not be therapeutic in this situation.
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 is displaying symptoms such as feeling tense, difficulty concentrating, disturbed sleep, and delusional thoughts about creatures hiding in his workplace. These symptoms indicate a return of psychotic features characteristic of schizophrenia, suggesting a relapse. This is supported by the patient's history of schizophrenia and the sudden onset of symptoms after a period of stability. Medication nonadherence (choice A) could be a possible cause, but the patient's symptoms are more indicative of a relapse. While psychoeducation (choice B) is important, the patient's current symptoms require immediate attention for relapse management. The chronic nature of his illness (choice C) is a general characteristic of schizophrenia and does not explain the current symptoms.
Question 3 of 5
A young patient diagnosed with schizophrenia is standing naked after showering and appears to be both dazed and indecisive. The nursing intervention that will be most helpful to promote dressing would be:
Correct Answer: B
Rationale: The correct answer is B. By saying, "These are your underpants. I'll help you put them on," the nurse provides clear guidance and offers assistance, which can help the patient feel more comfortable and supported in the dressing process. This approach acknowledges the patient's need for help while respecting their autonomy. Choice A is too directive and may make the patient feel pressured or overwhelmed. Choice C involves too many options, which can be confusing for a patient experiencing indecisiveness. Choice D assumes a problem with the clothes rather than focusing on the patient's needs and feelings. Overall, choice B is the most appropriate and supportive intervention in this situation.
Question 4 of 5
Which neurological deficit(s) would the nurse be most likely to encounter when assessing a patient diagnosed with schizophrenia?
Correct Answer: D
Rationale: The correct answer is D because in schizophrenia, patients may exhibit increased blinking and impaired fine motor skills due to medication side effects or neurological changes. Weakness, loss of function, droopy eyelids with reddened cornea, paralysis, and diminished reflexes are not commonly associated with schizophrenia. It is crucial for the nurse to recognize these neurological deficits to provide appropriate care and support for the patient.
Question 5 of 5
The client lives so completely in a world of her own that she does not eat, drink, or bathe regularly. She is considered to be:
Correct Answer: D
Rationale: The correct answer is D: Psychotic. The client's behavior of not eating, drinking, or bathing regularly indicates a severe detachment from reality, which is a hallmark of psychosis. Psychotic individuals may have delusions or hallucinations that distort their perception of the world, leading to extreme neglect of basic needs. Choices A, B, and C are incorrect because they do not specifically address the profound disconnect from reality exhibited by the client. Exotic refers to something unusual or rare, anorectic relates to an eating disorder, and neurotic typically involves anxiety and emotional instability, none of which fully capture the level of disconnection seen in psychosis.