ATI RN
Age Specific Patient Care Questions
Question 1 of 5
A patient admitted to the eating disorders unit has yellow skin, the extremities are cold, and the heart rate is 42 bpm. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient is quiet during the assessment saying only, "I will not eat until I lose enough weight to look thin." Select the best initial nursing diagnosis.
Correct Answer: D
Rationale: The correct initial nursing diagnosis is D: Imbalanced nutrition: less than body requirements related to self-starvation. The patient's symptoms indicate severe malnutrition from self-starvation, leading to the yellow skin, cold extremities, low heart rate, and underweight status. The patient's statement reflects their distorted perception of body image and the extreme measures taken to achieve thinness. Choice A (Anxiety related to fear of weight gain) is not the best initial diagnosis as it focuses on anxiety rather than the critical issue of malnutrition. Choice B (Disturbed body image related to weight loss) is not the best initial diagnosis as it does not address the immediate risk of severe malnutrition. Choice C (Ineffective coping related to lack of conflict resolution skills) is not the best initial diagnosis as it does not prioritize the life-threatening malnutrition present in this case.
Question 2 of 5
A depressed patient tells the nurse, "The bad things that happen are always my fault." How should the nurse respond to assist the patient to reframe this overgeneralization?
Correct Answer: D
Rationale: The correct answer is D because it encourages the patient to challenge the overgeneralization by exploring alternative explanations for a specific event. By examining one bad thing in detail, the patient can see that not everything is their fault, promoting a more balanced perspective. A is incorrect because it simply doubts the patient's statement without providing a constructive way to reframe it. B is incorrect as it introduces the idea of being a jinx, which may further reinforce the patient's negative self-perception. C is incorrect as it diverts the focus to good things, which does not address the patient's negative beliefs about themselves.
Question 3 of 5
A patient with schizophrenia refuses to take his medication because he believes he is not ill. What phenomenon most likely underlies this presentation?
Correct Answer: C
Rationale: The correct answer is C because anosognosia, a symptom of schizophrenia, can prevent patients from recognizing they are ill due to the illness itself affecting their insight and awareness. Anosognosia is a neurocognitive deficit common in schizophrenia, where the brain's ability to recognize one's own illness is impaired. This leads the patient to genuinely believe they are not ill, even when presented with evidence to the contrary. Choice A: Denial is a psychological defense mechanism, not a symptom of schizophrenia. Choice B: Stigma might influence perceptions of mental illness, but it does not directly cause anosognosia in schizophrenia. Choice D: Command hallucinations can influence behavior, but they typically involve auditory commands unrelated to recognizing one's illness.
Question 4 of 5
The patient on the mental health unit who should be assessed as being at highest risk for directing violent behavior toward others is the patient who has:
Correct Answer: B
Rationale: The correct answer is B because paranoid delusions of being followed by the Mafia indicate a high level of suspiciousness and potential for harm to others. This patient may act out violently in self-defense or as a reaction to perceived threats. Choice A is incorrect as OCD rituals are typically not associated with violent behavior. Choice C is incorrect as severe depression is more likely to result in self-harm rather than harm towards others. Choice D is incorrect as completed alcohol withdrawal and entering a rehabilitation program do not inherently indicate an increased risk of violent behavior towards others.
Question 5 of 5
A community mental health nurse receives a new client for his caseload. The diagnosis of the client is residual schizophrenia. Documentation states that the client has a number of negative symptoms. Which symptom would the nurse expect to assess in the client?
Correct Answer: D
Rationale: The correct answer is D: Emotional blunting. In residual schizophrenia, negative symptoms involve deficits in normal emotional responses and behaviors. Emotional blunting refers to a reduction in the intensity of emotional expression, which is commonly seen in clients with residual schizophrenia. This symptom can include a lack of facial expressions, reduced vocal inflections, and overall flat affect. Choice A (Bizarre, somatic delusions) is incorrect as it refers to a positive symptom of schizophrenia involving distorted beliefs about the body. Choice B (Disorganized speech pattern) is incorrect as it is characteristic of disorganized schizophrenia, not residual schizophrenia. Choice C (Catatonic posturing) is incorrect as it is a symptom of catatonic schizophrenia, not residual schizophrenia.