ATI RN
Concept of Family Health Nursing Care Questions
Question 1 of 5
A health care worker is exposed to blood from a patient who has HIV. What action should the worker take after the exposure?
Correct Answer: B
Rationale: The correct answer is B: Cleanse the site with soap and water. This is because soap and water effectively clean and disinfect the wound, reducing the risk of infection. Alcohol may not be as effective in removing bloodborne pathogens like HIV. Flushing with hot water can cause tissue damage and is not recommended. Applying a topical antibiotic is not necessary for blood exposure and may not prevent HIV transmission. Proper cleansing with soap and water is crucial to minimize the risk of infection following exposure to bloodborne pathogens like HIV.
Question 2 of 5
An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak?
Correct Answer: B
Rationale: The correct answer is B because alcohol withdrawal symptoms typically peak between 24 to 48 hours after the patient stops drinking. This timeframe aligns with the onset of symptoms such as tremors, anxiety, and hallucinations. Choices A, C, and D are incorrect because withdrawal symptoms do not peak within 6 to 8, 72, or 96 hours after drinking cessation. It is crucial for the nurse to monitor the patient closely during this critical period to manage and prevent potential withdrawal complications.
Question 3 of 5
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
Correct Answer: C
Rationale: The correct answer is C: Provide one-on-one supervision. This intervention has priority because the patient is experiencing hallucinations, agitation, and anxiety, which can pose a risk to their safety. One-on-one supervision ensures constant monitoring and immediate intervention if the patient's condition deteriorates. Checking the patient every 15 minutes (A) may not provide timely intervention. Encouraging fluid intake (B) is important but not the priority in this situation. Keeping the room dimly lit (D) may not address the patient's hallucinations and agitation adequately.
Question 4 of 5
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, 'After discharge, I’m sure everything will be just fine.' Which remark by the nurse will be most helpful to the spouse?
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the spouse's optimism while also gently highlighting the potential challenges that may arise during the recovery process. By pointing out that new problems may emerge as the patient adjusts to a life without alcohol, the nurse prepares the spouse for potential difficulties and encourages realistic expectations. Choice A is incorrect because it only acknowledges the spouse's support without addressing the potential challenges ahead. Choice C is incorrect because it focuses solely on stress avoidance rather than preparing for the overall adjustment process. Choice D is incorrect because it emphasizes monitoring the patient's behavior rather than addressing the spouse's outlook and potential struggles.
Question 5 of 5
A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, 'I feel terrible.' Which analysis is correct?
Correct Answer: C
Rationale: The correct analysis is C: Symptoms of opiate withdrawal are present. The patient's presentation of muscle aches, abdominal cramps, gooseflesh, and feeling terrible are classic symptoms of opiate withdrawal. Naloxone, as an opioid antagonist, reversed the effects of heroin leading to withdrawal symptoms. This is a typical response seen in patients who have been given naloxone to counteract opioid overdose. Choices A and B are incorrect as they do not align with the patient's clinical presentation and pharmacological understanding. Choice D is also incorrect as there is no indication that the patient has resumed heroin use.