ATI RN
Target Healthcare 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 presentation of yellow skin, cold extremities, bradycardia, low weight, and refusal to eat indicate severe malnutrition due to self-starvation. The key indicators are the physical signs of malnutrition and the patient's statement about not eating until they lose enough weight. Options A and B do not address the primary issue of malnutrition and self-starvation. Option C focuses on coping skills, which is not the priority in this case. Therefore, option D is the best initial nursing diagnosis to address the patient's life-threatening condition of malnutrition.
Question 2 of 5
A client with anorexia nervosa engages in manipulative behavior. She tells the nurse, 'I can't get weighed this morning, because I drank a glass of juice a few minutes before breakfast.' The best approach by the nurse would be:
Correct Answer: D
Rationale: Step 1: The correct answer is D because it sets clear boundaries and enforces consistency by reminding the client of the established protocol. Step 2: By stating "This is weight day. Please step on the scale," the nurse maintains the structure and accountability in the treatment plan. Step 3: This response avoids reinforcing manipulative behavior and emphasizes the importance of following the agreed-upon rules for accurate monitoring. Step 4: Other choices like A may inadvertently validate the manipulation, B suggests giving in to the client's avoidance tactic, and C delays the weighing without addressing the manipulation directly.
Question 3 of 5
The nurse who works in a sleep clinic knows that approximately ______% of adults suffer from insomnia.
Correct Answer: B
Rationale: The correct answer is B (30 to 40%). Insomnia is a common sleep disorder, affecting around 30-40% of adults. This range reflects the prevalence rates reported in various studies. Choices A, C, and D are incorrect because they provide prevalence rates that are either too low (A) or too high (C, D) compared to the generally accepted range for insomnia in adults. It is essential for the nurse in a sleep clinic to understand the prevalence of insomnia accurately to provide appropriate care and support to patients.
Question 4 of 5
A major difference in assessment findings between a patient with anorexia nervosa and a patient with bulimia nervosa is the patient with bulimia:
Correct Answer: C
Rationale: The correct answer is C because a major difference between anorexia nervosa and bulimia nervosa is that patients with bulimia are often of near-normal weight, while patients with anorexia are typically underweight. This is due to the different patterns of eating behaviors in the two disorders. In bulimia, individuals often engage in binge-eating episodes followed by compensatory behaviors such as purging, which may help maintain their weight. On the other hand, individuals with anorexia restrict their food intake significantly, leading to malnourishment and significant weight loss. Choice A is incorrect because individuals with bulimia can still experience malnourishment due to the purging behaviors. Choice B is incorrect because both patients with anorexia and bulimia may deny hunger due to their disordered eating behaviors. Choice D is incorrect because both disorders involve a distorted body image, although the specific nature of the distortion may differ.
Question 5 of 5
A 15-year-old boy presents with fatigue to the clinic. He reports that he is unable to wake up in the mornings and is missing a lot of school. On further questioning he reveals that he has some thoughts of suicide, but requests that the information be withheld from his parent who is in the waiting room. On examination he is noted to be obese with acanthosis. The next best step is to ensure his safety is:
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.