ATI RN
Population Specific Care Questions
Question 1 of 5
A male patient diagnosed with paranoid schizophrenia typically relates effectively with female staff but angrily tells the male nurse, 'You act like a homosexual. None of the men trust you or want to be around you.' The nurse, who is heterosexual, is perplexed by the patient's statements and discusses the event with his mentor. Which explanation most likely underlies the patient's behavior?
Correct Answer: D
Rationale: The correct answer is D because the patient is exhibiting the defense mechanism of projection by attributing his own uncomfortable feelings (homosexual urges) to the nurse. This defense mechanism allows the patient to disown his feelings and project them onto others. This behavior is common in individuals struggling with their own conflicting desires or impulses. Incorrect choices: A: Unconscious hostile feelings are not necessarily the root cause in this scenario. B: The patient's behavior is not about preemptively rejecting the nurse due to fear of rejection. C: While emotional intimacy may play a role, the patient's behavior is more about projection of his own feelings onto the nurse rather than distancing himself.
Question 2 of 5
A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most helpful response.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the victim's feelings without placing blame or judgment. By reflecting the victim's feelings back to them, the nurse validates their experience and shows empathy. This response encourages the victim to express their emotions and helps in building trust with the nurse. Other choices are incorrect: A: This choice does not address the victim's feelings of self-blame and does not provide the needed support. B: While this choice acknowledges the negative impact of self-blame, it does not directly address the victim's statement. C: This choice may be perceived as dismissive or blaming, which can further harm the victim's emotional well-being.
Question 3 of 5
A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
Correct Answer: D
Rationale: The correct answer is D: Respiratory depression. Flunitrazepam is a sedative-hypnotic drug that can cause central nervous system depression, leading to respiratory depression, which is life-threatening. Monitoring respiratory status is crucial to prevent respiratory failure. A: Coma may occur but is a consequence of severe respiratory depression, hence monitoring respiratory status is more critical. B: Seizures are not a common side effect of flunitrazepam and do not pose immediate life-threatening risks compared to respiratory depression. C: Hypotonia (muscle weakness) is a potential side effect but does not require immediate intervention like respiratory depression. In summary, monitoring for respiratory depression is the priority as it can lead to respiratory failure and death, while the other choices are not as immediately life-threatening.
Question 4 of 5
According to statistical research data, which of these children currently being followed by the pediatric nurse practitioner is at the greatest risk for fatal abuse?
Correct Answer: A
Rationale: The correct answer is A because young children with disabilities, like cerebral palsy, are at the highest risk for fatal abuse based on statistical research. These children may be more vulnerable due to their dependency on caregivers and communication challenges. Choice B is incorrect as measles, although serious, is not associated with fatal abuse. Choice C is incorrect as appendicitis is a medical condition and not a risk factor for abuse. Choice D is incorrect as a fractured humerus, while concerning, does not indicate a higher risk for fatal abuse compared to a child with cerebral palsy.
Question 5 of 5
The nurse is to perform a complete assessment of a client in her home, using the Mini-Mental State Examination as one component. When the nurse arrives, the client is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The client's husband says, 'Let's get on with this business.' The client is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be to:
Correct Answer: B
Rationale: The correct answer is B because conducting a Mini-Mental State Examination (MMSE) in a distracting environment with the client exhibiting signs of distress would likely yield inaccurate results. By explaining the importance of the testing process and rescheduling for a quieter day, the nurse ensures a more accurate assessment. This allows for a controlled environment conducive to obtaining reliable data. Choice A is incorrect because simply moving the husband and grandchildren to another room may not eliminate distractions or address the client's distress, potentially still impacting the accuracy of the assessment. Choice C is incorrect as relying solely on observations and reports from the family may not provide a comprehensive assessment of the client's cognitive function, as the MMSE is a standardized tool designed for objective evaluation. Choice D is incorrect as it does not address the immediate issue of conducting the assessment in a more suitable environment and may disrupt the client's routine by requiring a clinic visit.