ATI RN
Population Specific Care Questions
Question 1 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 2 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.
Question 3 of 5
An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
Correct Answer: B
Rationale: The correct answer is B: Place the client in a safe, nonstimulating environment. This is the most appropriate nursing intervention because the client is experiencing hallucinations and agitation, which could be due to the recent medication changes. Placing the client in a safe, calm environment can help reduce stimulation and provide a sense of security. This intervention addresses the client's immediate needs by ensuring her safety and promoting a sense of comfort. Incorrect answers: A: Interact with the client on an adult to child level - This is not appropriate as it does not address the client's current state of distress and could potentially worsen the situation. C: Ask client why she thinks someone would be trying to frighten her - This is not the priority at this time, as the client is experiencing hallucinations and agitation that need to be managed first. D: Explain to the family that the client will be restrained for her own good - Restraints should only be used as a last resort and should not be considered
Question 4 of 5
A client has just been diagnosed with mild Alzheimer's disease. A family member asks what medications are used for treatment. The nurse knows that which of the following medications are the ones most used for mild to moderate Alzheimer's disease? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Donepezil (Aricept). Donepezil is a cholinesterase inhibitor commonly used to treat mild to moderate Alzheimer's disease by improving cognitive function. It is considered a first-line medication for Alzheimer's. Haloperidol (A) is an antipsychotic drug and not used for Alzheimer's treatment. Rivastigmine (C) is another cholinesterase inhibitor like donepezil, but it is more commonly used for moderate to severe Alzheimer's. Nonsteroidal anti-inflammatory drugs (D) are not typically used for Alzheimer's treatment. In summary, Donepezil is the preferred medication for mild to moderate Alzheimer's due to its effectiveness in improving cognitive symptoms.
Question 5 of 5
Which of the following is an effective communication technique that should be included in the teaching plan for the family members of a woman in whom Alzheimer's disease has been diagnosed recently?
Correct Answer: A
Rationale: The correct answer is A: Use simple, familiar words, along with short and simple sentences. This is an effective communication technique for individuals with Alzheimer's disease as it helps in enhancing understanding and reduces confusion. Complex language or sentences may be difficult for the patient to comprehend. Choice B is incorrect because encouraging the client to sit during interactions does not directly relate to effective communication techniques. Choice C is incorrect as changing key words can lead to further confusion and may not aid in understanding. Choice D is incorrect because using hand gestures may not always effectively convey the message and can potentially cause more confusion for individuals with Alzheimer's disease.