ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
A patient is currently in an abusive relationship with the father of her only child and tells a nurse that her partner 'is really sorry for hitting me and wants to come back and be part of the family again.' The nurse should provide which intervention?
Correct Answer: B
Rationale: The correct answer is B: Identify groups that focus on treatment for individuals who are abusive. This intervention is appropriate because it addresses the root cause of the abusive behavior, which is the partner's abusive tendencies. By connecting the abuser to groups that specialize in treating abusive behavior, there is a chance for change and rehabilitation. A: Sharing with the patient that abusers seldom voluntarily stop abusing may not be helpful as it does not provide a proactive solution to address the abusive behavior. C: Telling the patient to continue the relationship and focus on minimizing the abuse is dangerous as it normalizes and enables the abusive behavior, putting the patient at further risk. D: Threatening the patient's partner with reporting to the police may escalate the situation and put the patient at higher risk of harm. It does not address the underlying issue of the partner's abusive behavior.
Question 2 of 5
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
Correct Answer: C
Rationale: The correct nursing diagnosis is "Disturbed thought processes" (C) because the client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disruption in their ability to think clearly and logically. This diagnosis reflects the client's cognitive dysfunction and disorganized thinking patterns. Choice A (Risk for violence) is incorrect because the client's behavior does not directly suggest a risk for violence towards others or themselves. Choice B (Defensive coping) is incorrect as the client's behavior is not indicative of using defensive mechanisms to cope with stress or anxiety. Choice D (Impaired memory) is incorrect as the client's symptoms are more indicative of thought processing issues rather than memory deficits. In summary, the client's presentation aligns closely with symptoms of disturbed thought processes, making it the most appropriate nursing diagnosis in this case.
Question 3 of 5
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
Correct Answer: A
Rationale: The correct answer is A: "This disorder responds well to treatment and, with follow-up, may not recur." Rationale: 1. Paranoid schizophrenia typically responds well to treatment, especially with early intervention. 2. With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and lead fulfilling lives. 3. Follow-up care and support are crucial in maintaining stability and preventing relapses. Summary of why other choices are incorrect: B: All types of schizophrenia are chronic relapsing disorders - This is not accurate as outcomes can vary depending on the subtype of schizophrenia. C: Outcomes are poor related to client prehospital disorganization - This statement is too general and does not specifically address the prognosis of paranoid schizophrenia. D: The usual outcome is that only partial remission is achieved - This is not always the case, as many individuals with paranoid schizophrenia can achieve full remission with appropriate treatment.
Question 4 of 5
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.
Correct Answer: A
Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms. Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.
Question 5 of 5
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention. Summary of Incorrect Choices: B: This question is important to assess if the voices are commanding potentially harmful actions. C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms. D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.