ATI RN
Age Specific Patient Care Questions
Question 1 of 5
A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should
Correct Answer: B
Rationale: The correct answer is B: question the order for restraint. Restraints should only be used as a last resort due to the potential risks and ethical considerations. In this scenario, the prescription of restraint seems unnecessary and should be questioned to ensure the resident's safety and well-being. The other choices are incorrect because questioning the fluid restriction (A) is not necessary as it aligns with the resident's needs, transcribing the prescriptions as written (C) would be inappropriate without considering the necessity of each order, and assessing the resident's bowel elimination (D) is important but not the immediate concern indicated by the order for restraint.
Question 2 of 5
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin." Select the best initial nursing diagnosis.
Correct Answer: D
Rationale: The correct initial nursing diagnosis is D: Imbalanced nutrition: less than body requirements related to self-starvation. The patient's symptoms indicate severe malnutrition from self-starvation, leading to the yellow skin, cold extremities, low heart rate, and underweight status. The patient's statement reflects their distorted perception of body image and the extreme measures taken to achieve thinness. Choice A (Anxiety related to fear of weight gain) is not the best initial diagnosis as it focuses on anxiety rather than the critical issue of malnutrition. Choice B (Disturbed body image related to weight loss) is not the best initial diagnosis as it does not address the immediate risk of severe malnutrition. Choice C (Ineffective coping related to lack of conflict resolution skills) is not the best initial diagnosis as it does not prioritize the life-threatening malnutrition present in this case.
Question 3 of 5
A patient is hospitalized for severe depression. Of the medications listed below, the nurse can expect to provide the patient with teaching about:
Correct Answer: C
Rationale: Rationale: 1. Severe depression is typically treated with antidepressants like Sertraline (Zoloft). 2. Sertraline is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. 3. The nurse should provide teaching on how to take the medication, potential side effects, and monitoring for effectiveness. 4. Other choices (A, B, D) are not typically used as first-line treatment for severe depression and may not be appropriate for this patient.
Question 4 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 5 of 5
A patient with schizophrenia refuses to take his medication because he believes he is not ill. What phenomenon most likely underlies this presentation?
Correct Answer: C
Rationale: The correct answer is C because anosognosia, a symptom of schizophrenia, can prevent patients from recognizing they are ill due to the illness itself affecting their insight and awareness. Anosognosia is a neurocognitive deficit common in schizophrenia, where the brain's ability to recognize one's own illness is impaired. This leads the patient to genuinely believe they are not ill, even when presented with evidence to the contrary. Choice A: Denial is a psychological defense mechanism, not a symptom of schizophrenia. Choice B: Stigma might influence perceptions of mental illness, but it does not directly cause anosognosia in schizophrenia. Choice D: Command hallucinations can influence behavior, but they typically involve auditory commands unrelated to recognizing one's illness.