ATI RN
Population Based Health Care Questions
Question 1 of 5
A mother discusses her concerns about genetic transmission of schizophrenia with the nurse saying, 'My son is a fraternal twin. He has been diagnosed with schizophrenia. Will my other son develop schizophrenia, too?' The response that is both sensitive and shows understanding of the genetic component is:
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate and sensitive response. Fraternal twins do not share the same genetic makeup as identical twins, so the genetic risk for the other twin developing schizophrenia is lower. By acknowledging this fact, the nurse offers reassurance to the mother without giving false hope or inaccurate statistics. This response shows understanding of the genetic component of schizophrenia and addresses the mother's concerns in a compassionate and informative manner. Choices A, B, and C are incorrect: A: This response is dismissive of the mother's concerns and does not provide any helpful information. It also lacks sensitivity and empathy towards the mother's situation. B: This response provides an inaccurate statistic about the likelihood of the other twin developing schizophrenia. It does not consider the difference between identical and fraternal twins, leading to a potentially misleading statement. C: This response is vague and does not address the mother's question directly. It does not provide any useful information or reassurance, leaving the mother uncertain and anxious about
Question 2 of 5
A patient with many positive symptoms of schizophrenia, whose behavior is disorganized and who is highly anxious, tells the nurse in the psychiatric emergency department, 'You have got to help me. I do not know what is going on. I think someone is trying to wipe me out. I have to get a gun.' The patient, a college student, lives alone and has no family or support system in the immediate area. He has not left his room in 2 weeks, has not eaten in several days, and is unkempt. Of the available treatment settings, the nurse should recommend:
Correct Answer: B
Rationale: The correct answer is B: inpatient hospitalization on a locked unit. This option is the most appropriate because the patient is presenting with severe symptoms of schizophrenia, including paranoia, disorganized behavior, and potential harm to self or others by mentioning getting a gun. In this case, the patient requires a higher level of care and safety, which can only be provided in an inpatient hospital setting on a locked unit. Admission to an unlocked residential crisis unit (Choice A) may not provide the necessary level of supervision and security. Attending a day treatment program for 4 weeks (Choice C) may not be intensive enough to address the patient's current crisis. Admission to a partial hospital program (Choice D) also may not provide the required level of supervision and structure for a patient with such acute symptoms.
Question 3 of 5
A nurse is working with a perpetrator of family violence who has a long history of violent rages when frustrated, with periods of remorse after each outburst. The nurse is most likely to establish the nursing diagnosis of:
Correct Answer: C
Rationale: The correct answer is C: Ineffective coping related to poor anger management. This nursing diagnosis is appropriate because it addresses the perpetrator's inability to manage their anger effectively, leading to violent outbursts. The perpetrator's history of violent rages and subsequent remorse suggest a pattern of maladaptive coping mechanisms. This diagnosis focuses on the underlying issue of poor anger management, which is essential to address in order to prevent future acts of violence. Choices A, B, and D are incorrect: A: Risk for injury related to victim reprisal - This choice places the focus on potential harm to the victim as a result of retaliation, which is not the primary issue in this scenario. B: Risk for other-directed violence related to stress - While stress may contribute to the perpetrator's behavior, the primary issue lies in their poor anger management rather than just stress. D: Caregiver role strain related to feelings of being overwhelmed - This choice is not appropriate as it does not address the core issue of poor
Question 4 of 5
Which aspect of assessment has priority when a nurse interviews a rape victim?
Correct Answer: A
Rationale: The correct answer is A: Coping mechanisms the patient is using. This aspect has priority because it helps the nurse assess the immediate emotional and psychological impact of the trauma on the victim. Understanding coping mechanisms can guide the nurse in providing appropriate support and interventions. Choice B is incorrect as past sexual experiences are not as pertinent during the immediate assessment of a rape victim. Choice C is incorrect as assessing interpersonal relationships may not be a priority during the initial interview. Choice D is incorrect as the presence of a sexually transmitted disease is not the primary concern when assessing a rape victim.
Question 5 of 5
A friend brings a teenager to the emergency department. The friend found the patient unconscious in a bedroom at a party. Semen is observed on the patient's underclothes. Priority actions by the nurse should focus on:
Correct Answer: B
Rationale: The correct answer is B: Maintaining the patient's airway. This is the priority action because the patient is unconscious and airway patency is crucial for survival. Preserving rape evidence (A) can be important, but the patient's immediate health takes precedence. Obtaining a description of the rape (C) can wait until the patient's condition stabilizes. Determining what drugs were ingested (D) is important but secondary to ensuring the patient can breathe.