ATI RN
Age Specific Patient Care Questions
Question 1 of 5
A depressed patient tells the nurse, "The bad things that happen are always my fault." How should the nurse respond to assist the patient to reframe this overgeneralization?
Correct Answer: D
Rationale: The correct answer is D because it encourages the patient to challenge the overgeneralization by exploring alternative explanations for a specific event. By examining one bad thing in detail, the patient can see that not everything is their fault, promoting a more balanced perspective. A is incorrect because it simply doubts the patient's statement without providing a constructive way to reframe it. B is incorrect as it introduces the idea of being a jinx, which may further reinforce the patient's negative self-perception. C is incorrect as it diverts the focus to good things, which does not address the patient's negative beliefs about themselves.
Question 2 of 5
The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has:
Correct Answer: B
Rationale: The correct answer is B because paranoid delusions of being followed by the Mafia indicate a high level of suspiciousness and potential for harm to others. This patient may act out violently in self-defense or as a reaction to perceived threats. Choice A is incorrect as OCD rituals are typically not associated with violent behavior. Choice C is incorrect as severe depression is more likely to result in self-harm rather than harm towards others. Choice D is incorrect as completed alcohol withdrawal and entering a rehabilitation program do not inherently indicate an increased risk of violent behavior towards others.
Question 3 of 5
A community mental health nurse receives a new client for his caseload. The diagnosis of the client is residual schizophrenia. Documentation states that the client has a number of negative symptoms. Which symptom would the nurse expect to assess in the client?
Correct Answer: D
Rationale: The correct answer is D: Emotional blunting. In residual schizophrenia, negative symptoms involve deficits in normal emotional responses and behaviors. Emotional blunting refers to a reduction in the intensity of emotional expression, which is commonly seen in clients with residual schizophrenia. This symptom can include a lack of facial expressions, reduced vocal inflections, and overall flat affect. Choice A (Bizarre, somatic delusions) is incorrect as it refers to a positive symptom of schizophrenia involving distorted beliefs about the body. Choice B (Disorganized speech pattern) is incorrect as it is characteristic of disorganized schizophrenia, not residual schizophrenia. Choice C (Catatonic posturing) is incorrect as it is a symptom of catatonic schizophrenia, not residual schizophrenia.
Question 4 of 5
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his specific delusion of food being poisoned. By allowing the client to select food from vending machines, he can choose items he believes are safe, which can help alleviate his paranoia and increase his trust in the care being provided. This approach promotes a therapeutic relationship and empowers the client in making choices about his care. Explanation of why other choices are incorrect: A: Explaining that others eat the food and are not harmed may not be effective as the client's delusion is strong, and rational arguments may not be helpful in this case. C: Assisting with personal hygiene and grooming is important but does not directly address the client's delusion about food being poisoned. D: Not allowing the client to verbalize delusional thoughts can escalate the client's distress and hinder the therapeutic relationship. It is essential to acknowledge the client's experiences and work towards building trust and rapport
Question 5 of 5
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.