ATI RN
Age Specific Care Questions
Question 1 of 5
A patient experiencing delirium secondary to corticosteroid toxicity is manifesting paranoid thinking and noisy, assaultive behavior. The patient is currently pacing the hall and shouting. A nurse has placed a call to the physician and is anticipating the following order:
Correct Answer: A
Rationale: The correct answer is A: the use of supervised restraints. In this situation, the patient is displaying agitated and assaultive behavior, posing a risk to themselves and others. Supervised restraints are necessary to ensure the safety of the patient and healthcare providers until the effects of corticosteroid toxicity subside. Restraints should only be used as a last resort when other interventions have failed. Choice B: A loading dose of phenytoin is incorrect because phenytoin is not indicated for managing delirium secondary to corticosteroid toxicity. Choice C: A small dose of prednisone is incorrect because adding more corticosteroids would exacerbate the toxicity and worsen the delirium. Choice D: An IV dose of thiamine is incorrect as thiamine is used to treat thiamine deficiency, not corticosteroid toxicity-induced delirium.
Question 2 of 5
A nursing intervention that will be planned to occur early in the nurse-patient relationship with a client with an eating disorder is:
Correct Answer: A
Rationale: The correct answer is A: formulating a nurse-client contract. This intervention is essential early in the nurse-patient relationship with a client with an eating disorder because it establishes clear boundaries, roles, and expectations. By creating a contract, both the nurse and the client can communicate openly about their goals, responsibilities, and treatment plan. This helps build trust, promotes collaboration, and provides a framework for the therapeutic relationship. Choices B, C, and D are incorrect: B: Using confrontation to attack denial may be counterproductive and harmful in the early stages of the relationship as it can lead to resistance and damage trust. C: Placing the client in a therapeutic group may be beneficial at a later stage but not necessarily an appropriate early intervention when individual needs should be addressed first. D: Attacking enmeshment by separating client and family is not a suitable early intervention as it may cause distress and disrupt important support systems.
Question 3 of 5
A client with an eating disorder that has resulted in weight loss to a point 15% below normal weight tells the nurse, 'I don't need to be hospitalized. I can control myself.' The nurse continues to prepare the client for hospitalization because the vicious cycle of eating disorder behavior is fueled by:
Correct Answer: A
Rationale: The correct answer is A: feelings of power and control resulting from weight loss. In clients with eating disorders, the behavior is often driven by a sense of control and power gained through weight loss. This reinforces the cycle of the disorder as the individual feels empowered by their ability to restrict food intake. This false sense of control becomes a driving force in the continuation of the disorder. Incorrect answers: B: Dysfunctional family dynamics may contribute to the development of an eating disorder, but in this scenario, the client's refusal for hospitalization is more related to their own sense of control rather than family dynamics. C: Faulty use of the defense mechanism projection is not the primary reason for the client's resistance to hospitalization in this case. D: Lack of superego constraints on behavior is not the main factor driving the client's refusal for hospitalization.
Question 4 of 5
Children should undergo further evaluation when their weight is % above their height.
Correct Answer: C
Rationale: The correct answer is C (20%). This is because a weight that is 20% above a child's height can indicate potential health issues such as obesity. Excess weight can lead to various health problems in children. Choices A, B, and D are incorrect as they represent lower percentages, which may not be as concerning in terms of potential health risks. It is important to consider a higher percentage threshold for further evaluation to ensure early detection and intervention for any weight-related issues.
Question 5 of 5
A nurse has completed the assessment for a patient who has a maladaptive response to eating regulation. Findings include the following: height, 5 feet 3 inches; current weight, 80 pounds with weight loss of 30% of body weight over the past 3 months; T, 96.6m F; BP, 68/40; P, 40; R, 20; poor skin turgor; lanugo; amenorrhea of 6 months' duration; admits to restricting intake to 350 calories daily; dissatisfied with eating pattern as evidenced by patient statement, 'I need to lose another 10 pounds to be at an ideal weight.' These assessment findings are most consistent with the medical diagnosis of:
Correct Answer: B
Rationale: The correct answer is B: Anorexia nervosa. The assessment findings align with the diagnostic criteria for anorexia nervosa, including significant weight loss, restrictive eating patterns, distorted body image, amenorrhea, and physical signs like poor skin turgor and lanugo. The patient's extreme weight loss, restrictive calorie intake, dissatisfaction with weight despite being underweight, and other physical and psychological symptoms are classic indicators of anorexia nervosa. Incorrect Choices: A: Bulimia nervosa involves binge eating followed by compensatory behaviors, which are not evident in this case. C: Binge-eating disorder involves recurrent episodes of binge eating without compensatory behaviors, which are not present here. D: Disturbed body image may be present in anorexia nervosa, but the key features of weight loss, restrictive eating, and amenorrhea are more indicative of anorexia nervosa.