ATI RN
Concept of Family Health Nursing Care Questions
Question 1 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 2 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.
Question 3 of 5
Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis?
Correct Answer: B
Rationale: The correct answer is B: Disturbed thought processes. Both patients with paranoid schizophrenia and amphetamine-induced psychosis commonly experience altered thinking patterns, hallucinations, and delusions. This nursing diagnosis addresses the cognitive disruptions present in both conditions. Incorrect choices: A: Powerlessness - This diagnosis refers to a lack of control over one's life situation, which may not be a primary concern for these patients. C: Ineffective thermoregulation - This diagnosis relates to the body's ability to maintain temperature, which is not typically affected in these conditions. D: Impaired oral mucous membrane - This diagnosis is related to issues with the mouth's lining and is not typically associated with paranoid schizophrenia or amphetamine-induced psychosis.
Question 4 of 5
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse’s first action?
Correct Answer: D
Rationale: The correct answer is D: Establish a patent airway. The first action in any emergency situation involving an unconscious person is to ensure their airway is open and clear to facilitate breathing. This is crucial for maintaining oxygenation and preventing potential complications like hypoxia. Testing reflexes (A) and checking pupils (B) are important assessments but not the immediate priority in this situation. Initiating vomiting (C) is contraindicated as it can lead to further complications, especially if the person has ingested a potentially harmful substance.
Question 5 of 5
Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, the patient will
Correct Answer: B
Rationale: The correct answer is B because stating 'I see the need for ongoing treatment' demonstrates insight and willingness to engage in further treatment, indicating a readiness for change. This is crucial for someone who has completed multiple detox programs in a short period. Choice A (using rationalization in healthy ways) may not address the underlying issues leading to repeated detox programs. Choice C (identifying constructive outlets for expression of anger) is important but not the most urgent concern after detox. Choice D (developing a trusting relationship with one staff member) is beneficial but does not address the need for ongoing treatment.