ATI RN
Age Specific Care Competency Questions
Question 1 of 5
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
Correct Answer: A
Rationale: The correct answer is A: Idea of reference. This term refers to the belief that neutral events are directed at oneself. In this case, the patient's interpretation of doctors talking as a plot against him signifies a misinterpretation of reality. Delusion of infidelity (B) involves belief in a partner's unfaithfulness, which is not applicable here. Auditory hallucination (C) involves hearing voices, not relevant to this scenario. Echolalia (D) is the repetition of words spoken by others, not demonstrated in the patient's behavior. Thus, A is the most appropriate identification for this behavior.
Question 2 of 5
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. The client occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The best response for the nurse to make would be:
Correct Answer: B
Rationale: The correct answer is B: "Who do you mean when you say 'everybody'?" This response is the best because it acknowledges the client's feelings and seeks clarification. By asking for specifics, the nurse can gain a better understanding of the client's perceptions and experiences, which can help in providing appropriate care and support. Choice A: "That's really too bad." This response lacks empathy and does not address the client's concerns directly. Choice C: "What difference does frobitzing make?" This response is dismissive and does not focus on the client's feelings or experiences. Choice D: "Why do they frobitz?" This response is confrontational and may make the client feel defensive, hindering effective communication and rapport-building.
Question 3 of 5
A client with catatonic schizophrenia has been posturing, standing with his left arm upraised and his right foot off the floor. For the most part, he ignores attempts at nursing intervention but will occasionally walk, sit, or lie down for a few minutes. The client eats standing up if the nurse brings a tray to the room. The priority nursing order would be to:
Correct Answer: B
Rationale: The correct answer is B. Assess for lower extremity edema bid. Rationale: 1. Priority is to assess for lower extremity edema as the client is standing for extended periods, which can lead to edema. 2. Edema assessment is crucial for preventing complications like blood clots or skin breakdown. 3. Insisting on sitting or lying down may aggravate the client and worsen the situation. 4. Providing high-calorie drinks or activities therapy are not the immediate priority in this case. In summary, assessing for lower extremity edema is crucial due to the client's prolonged standing, which can lead to potential health risks, making it the priority nursing order.
Question 4 of 5
A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, 'They're all plotting to destroy me. Isn't that true?' Which would be the most appropriate response?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and validates the patient's feelings without agreeing with the delusion. By acknowledging the patient's fear, the nurse can establish trust and rapport, which are crucial in therapeutic communication. This response shows understanding and compassion, helping to de-escalate the situation and provide a supportive environment for the patient. Choice A is incorrect as it denies the patient's belief and may lead to increased agitation. Choice B is incorrect as it challenges the patient's delusion, which can worsen the situation and lead to further confrontation. Choice D is incorrect as it dismisses the patient's feelings and may cause the patient to become defensive or feel misunderstood.
Question 5 of 5
The nurse is sitting with a patient diagnosed as having schizophrenia, disorganized type, who starts to laugh uncontrollably, although nothing funny has occurred. The nurse should say:
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the patient's behavior in a non-confrontational manner and invites the patient to share their experience. By saying "You're laughing. Tell me what's happening," the nurse shows empathy and encourages open communication. Choice A may unintentionally minimize the patient's experience. Choice B may come off as accusatory. Choice C doesn't actively engage the patient in conversation. Encouraging the patient to express their feelings can help establish trust and facilitate therapeutic communication.