ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
A nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Select the nurse's best comment.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the behavior in relation to the agreed-upon plan and sets clear boundaries. By stating that exercising is not permitted until the patient has gained a specific amount of weight, the nurse reinforces the importance of following the treatment plan to ensure the patient's health and well-being. A: This response does not address the behavior in a constructive manner and may come across as judgmental. B: While discussing the problem is important, it does not provide clear guidance on addressing the immediate issue of exercising before reaching the weight goal. C: While discussing the relationship between exercise and weight loss can be helpful, it does not provide a clear directive on what action should be taken in this specific situation.
Question 2 of 5
A patient with bipolar disorder, mania, relapsed after discontinuing lithium. The health care provider prescribes lithium 600 mg BID and olanzapine (Zyprexa) 10 mg BID. What is the rationale for addition of olanzapine to the lithium regime? It will:
Correct Answer: B
Rationale: The correct answer is B: Bring hyperactivity under rapid control. Rationale: 1. Olanzapine is an atypical antipsychotic known for its rapid onset of action in controlling manic symptoms, including hyperactivity. 2. Lithium alone may take time to reach therapeutic levels and show efficacy, while olanzapine can provide more immediate relief. 3. Combining olanzapine with lithium can address acute manic symptoms effectively and quickly. 4. Choice A is incorrect because olanzapine does not specifically minimize lithium's side effects. 5. Choice C is incorrect as olanzapine does not directly potentiate lithium's antimanic action. 6. Choice D is incorrect because olanzapine is typically used for acute symptom management rather than long-term control.
Question 3 of 5
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect _____ and should _____.
Correct Answer: A
Rationale: The correct answer is A: Neuroleptic malignant syndrome. The patient is exhibiting symptoms consistent with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, elevated temperature, and vital sign changes are classic signs of NMS. Treatment includes immediate cooling to lower the body temperature and transfer to the intensive care unit for close monitoring and supportive care. Choice B: Anticholinergic toxicity does not fit the patient's presentation as there are no specific signs of anticholinergic toxicity such as dry mucous membranes, dilated pupils, or tachycardia. Choice C: Relapse of psychosis is unlikely to present with the same constellation of symptoms, including altered mental status, fever, and vital sign changes. Choice D: Agranulocytosis is characterized by a severe drop in white blood cells, leading to increased risk of infection, but it does
Question 4 of 5
A client displays disorganized thinking, difficult-to-follow speech, and silly, inappropriate affect. The client isolates himself from other clients and staff, ignores unit activities, and often seems to be listening and responding to unseen stimuli. This client's behavior most closely conforms to the characteristic behavior of:
Correct Answer: D
Rationale: The correct answer is D: Disorganized schizophrenia. The client's symptoms of disorganized thinking, difficult-to-follow speech, inappropriate affect, social withdrawal, and hallucinations (responding to unseen stimuli) align with the diagnostic criteria for Disorganized Schizophrenia. This subtype is characterized by disorganized behavior, speech, and affect, as well as social withdrawal and hallucinations. A: Residual schizophrenia does not involve active psychotic symptoms like hallucinations or delusions, which are present in the client's behavior described. B: Schizoaffective disorder combines symptoms of schizophrenia and mood disorders, and the client's symptoms do not strongly suggest a mood disorder component. C: Paranoid schizophrenia typically involves prominent delusions and auditory hallucinations, which are not emphasized in the client's behavior described.
Question 5 of 5
The nurse is administering haloperidol (Haldol) to a client experiencing delusions and hallucinations associated with schizophrenia. The nurse can expect symptom abatement as a result of the drug's action to:
Correct Answer: B
Rationale: The correct answer is B because haloperidol is a typical antipsychotic that works by blocking dopamine receptors in the brain. By blocking these receptors, haloperidol reduces the effects of excess dopamine, which is known to contribute to symptoms of schizophrenia such as delusions and hallucinations. This action helps alleviate the positive symptoms of schizophrenia. Choice A is incorrect because haloperidol does not reduce the number of brain cells that crave dopamine; it acts on the receptors themselves. Choice C is incorrect because enhancing dopamine receptors would lead to an increase in the effects of dopamine, worsening symptoms. Choice D is incorrect because haloperidol does not cause increased cellular production of dopamine; it blocks dopamine receptors instead.