ATI RN
Concept of Family Health Care Questions
Question 1 of 5
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. This is the priority nursing diagnosis because the patient's current state of agitation and anxiety, coupled with the belief of bugs crawling on the bed, poses an immediate risk for self-injury. The patient's altered mental status and intoxication increase the likelihood of accidental harm. Explanation for other choices: A: Ineffective airway clearance - While this is always a critical concern, the patient's current presentation does not indicate any immediate threat to the airway. B: Ineffective coping - While the patient may be experiencing distress, the primary focus should be on addressing the risk of injury given the patient's altered mental status. C: Ineffective denial - While the patient may be experiencing hallucinations, the primary concern is the risk of injury rather than the patient's denial of the situation.
Question 2 of 5
When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur?
Correct Answer: B
Rationale: The correct answer is B: Tolerance develops. Tolerance occurs when the body adapts to repeated exposure to alcohol, requiring higher doses to achieve the same effect. Initially, two drinks were sufficient, but over time, the body adjusts, leading to the need for four drinks to achieve the same level of relaxation and drowsiness. This change is not due to the alcohol being less potent (A), antagonistic effects (C), or hypomagnesemia (D). Tolerance is a well-documented phenomenon in the context of alcohol consumption, explaining the increased amount needed to achieve the desired effect.
Question 3 of 5
A nurse with a history of narcotic dependence is found unconscious in the hospital locker room after overdosing. The nurse is transferred to the inpatient chemical dependence unit for care. Which attitudes or behaviors by nursing staff may be enabling?
Correct Answer: A
Rationale: The correct answer is A because conveying understanding that pressures associated with nursing practice underlie substance use may enable the nurse's behavior by justifying or excusing the substance dependence. This attitude may inadvertently support the nurse's addiction by overlooking the need for accountability and treatment. Choices B, C, and D are incorrect because: B: Pointing out that work problems are the result, but not the cause, of substance dependence does not enable the behavior. It acknowledges the issue without excusing or enabling it. C: Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing is not enabling behavior. It shows support and understanding without condoning the substance misuse. D: Providing health teaching about stress management is not enabling behavior. It focuses on addressing the underlying issues rather than enabling or excusing the substance dependence.
Question 4 of 5
Which assessment findings will the nurse expect in an individual who has just injected heroin?
Correct Answer: D
Rationale: The correct answer is D: Drowsiness, constricted pupils, slurred speech. After injecting heroin, the individual experiences a rapid onset of effects due to the drug's ability to quickly cross the blood-brain barrier. The central nervous system is depressed, leading to drowsiness and sedation. Heroin causes constriction of the pupils (miosis) due to its effect on the autonomic nervous system. The individual may also exhibit slurred speech due to the drug's impact on cognitive and motor functions. Incorrect Choices: A: Anxiety, restlessness, paranoid delusions - These symptoms are more commonly associated with stimulant drugs like cocaine or amphetamines. B: Heightened sexuality, insomnia, euphoria - These effects are more commonly seen with stimulant drugs rather than heroin. C: Muscle aching, dilated pupils, tachycardia - Muscle aching and tachycardia are signs of opioid withdrawal rather than immediate effects of heroin use. Dil
Question 5 of 5
A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, 'Often my friend drinks, along with taking more of the drug than is ordered.' What is the effect of the use of alcohol with this drug?
Correct Answer: C
Rationale: The correct answer is C: A synergistic effect occurs. When alcohol is consumed with pentobarbital sodium, both substances depress the central nervous system. This results in an enhanced sedative effect, leading to respiratory depression, coma, and potentially death. The combined effect of the two substances is greater than the sum of their individual effects. Choices A and B are incorrect as alcohol does not stimulate the metabolism of pentobarbital sodium nor diminish its effect. Choice D is also incorrect as there is a significant effect when alcohol is combined with this drug.