ATI RN
Target Healthcare Questions
Question 1 of 5
A patient, aged 77 years, has Alzheimer's disease and lives with her daughter. While checking her blood pressure at the clinic, the nurse noticed fresh bruises on the patient's palms and buttocks. The patient could not explain these bruises. The nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage. She stated, "My mother is getting worse every week. She is not my mother anymore. She can't recognize me, and she wanders all night. We take turns because she has to be watched constantly. Last night I fell asleep, and she fell down the stairs while wandering." Which statement is most accurate?
Correct Answer: A
Rationale: Step 1: The nurse observed bruises on the patient's palms and buttocks. Step 2: The patient could not explain these bruises. Step 3: The daughter mentioned the patient's worsening condition and the incident of falling down the stairs. Step 4: The daughter's statement indicates the patient's deteriorating cognitive and physical abilities. Step 5: The daughter's challenges in managing the patient are due to the progression of Alzheimer's disease. Step 6: There is no explicit evidence or indication of elder abuse based on the provided information. Step 7: Reporting the injuries without clear signs of abuse may harm the patient's relationship with the daughter. Step 8: Therefore, the most appropriate action is not to report the injuries based on the available data to avoid potential harm. Summary: - Choice A is correct as reporting the injuries is not indicated by the available data. - Choices B, C, and D are incorrect as there is no clear evidence of elder abuse in the scenario
Question 2 of 5
A new client admits to having been battered by her live-in boyfriend several times over the past 2 years. She states to the nurse, 'We plan to get married next June, and I think things will be better then. He is always so sorry afterward, that I think I can trust him to change.' Which intervention should be included in the client's teaching plan?
Correct Answer: D
Rationale: The correct answer is D: Assist her in developing an emergency plan, since the pattern of violence is likely to continue. This choice is correct because it focuses on safety planning, which is crucial for individuals in abusive relationships. By helping the client develop an emergency plan, the nurse is acknowledging the seriousness of the situation and providing practical strategies to ensure her safety. It is important to have a plan in place in case of future violence. Explanation for the incorrect choices: A: Supporting her hope that the battering will end after they are married is not appropriate as it may give false hope and does not address the immediate safety concerns. B: Enrolling in a self-defense class may not be effective in situations of domestic violence as it can escalate the violence and may not address the underlying issues causing the abuse. C: Emphasizing that the battering pattern usually remains the same in frequency and severity over time is not as helpful as developing a concrete safety plan to address the immediate danger.
Question 3 of 5
Which symptom reported by a client, age 35, who was sexually abused as a child reflects the diagnosis of posttraumatic stress disorder (PTSD)?
Correct Answer: A
Rationale: The correct answer is A: Reexperiencing the traumatic event. This symptom is a key criterion for diagnosing PTSD according to the DSM-5. It includes flashbacks, nightmares, or intrusive thoughts related to the traumatic event. This symptom indicates that the client is experiencing distressing memories of the past abuse, which is a common feature of PTSD. Choice B is incorrect because it describes agoraphobia, a separate anxiety disorder, not specific to PTSD. Choice C is incorrect as seeking advice is not a diagnostic criterion for PTSD. Choice D is incorrect because ruminating over the abuse with others may reflect coping mechanisms or seeking support, but it does not necessarily indicate PTSD.
Question 4 of 5
A client diagnosed with Alzheimer's disease has a catastrophic reaction during an activity involving simultaneous playing of music and working on a craft project. The client starts shouting 'no, no, no' and rushes out of the room. The nurse should:
Correct Answer: B
Rationale: The correct answer is B. The nurse should follow the client, reassure her, and redirect her to a quieter activity. This approach acknowledges the client's feelings and provides support to help her calm down. Isolating the client (Choice A) may escalate the situation and not address the underlying cause of the reaction. Discontinuing the activity program (Choice C) is not the best option as it may limit the client's engagement and therapeutic benefits. Giving medication and restricting activity (Choice D) should be a last resort and not the initial response to a behavioral reaction. In summary, Choice B focuses on comforting and redirecting the client, promoting a positive and supportive environment.
Question 5 of 5
The nurse is administering donepezil (Aricept) to a client with stage 1 Alzheimer's disease. Based on this drug's mechanism of action, the nurse will seek evidence of improvement in the client's:
Correct Answer: A
Rationale: The correct answer is A: Ability to remember. Donepezil is a cholinesterase inhibitor that works by increasing levels of acetylcholine in the brain, which helps improve cognitive function, particularly memory. Therefore, the nurse should seek evidence of improvement in the client's ability to remember. Choice B: Ability to tolerate stress is incorrect because donepezil does not directly impact stress tolerance. Choice C: Social behaviors is incorrect as donepezil primarily targets memory and cognitive function, not social behaviors. Choice D: Delusions and hallucinations is incorrect because donepezil does not specifically address these symptoms, which are more commonly associated with psychosis rather than Alzheimer's disease.