ATI RN
Age Specific Care Questions
Question 1 of 5
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
Correct Answer: D
Rationale: The correct answer, D, is indicative of auditory hallucinations. Darting eyes may suggest that the patient is hearing voices, distracted behavior aligns with responding to internal stimuli, and mumbling to oneself could be a response to hearing voices. Choices A, B, and C do not directly relate to auditory hallucinations, as they are more indicative of other mental health symptoms such as social withdrawal, mania, anxiety, or compulsive behaviors. Selecting D helps identify potential auditory hallucinations based on observed behaviors associated with hearing voices.
Question 2 of 5
The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a patient with schizophrenia who demonstrates auditory hallucinations, apathy, anhedonia, and poor social functioning. The patient is overweight and has hypertension. Bearing these facts in mind, the drug the nurse should advocate would be:
Correct Answer: D
Rationale: The correct answer is D: aripiprazole (Abilify). Aripiprazole is a second-generation antipsychotic that is less likely to cause weight gain and metabolic side effects compared to other antipsychotics. This is important since the patient is already overweight and has hypertension. Aripiprazole also has a lower risk of causing sedation, which can be beneficial for addressing apathy and anhedonia without worsening social functioning. A: Clozapine is effective for treatment-resistant schizophrenia but is associated with significant weight gain and metabolic side effects. B: Haloperidol is a first-generation antipsychotic with a high risk of extrapyramidal side effects and is not ideal for a patient with hypertension. C: Olanzapine is known for causing significant weight gain and metabolic effects, making it a less suitable choice for an overweight patient with hypertension.
Question 3 of 5
The nursing diagnosis most likely to be used for a person who has a diagnosis of schizophrenia, paranoid type, is:
Correct Answer: A
Rationale: Step-by-step rationale for choice A: 1. Schizophrenia, paranoid type, involves mistrust and suspicion. 2. Impaired ability to trust can lead to social isolation. 3. "Impaired ability to trust" directly relates to social isolation. 4. Therefore, "social isolation related to impaired ability to trust" is the most likely nursing diagnosis. Summary of other choices: - B: Not directly related to mistrust in paranoid schizophrenia. - C: Lack of confidence in significant others is not a defining characteristic of paranoid schizophrenia. - D: Impaired memory is not a primary feature of paranoid schizophrenia.
Question 4 of 5
A patient diagnosed with schizophrenia approaches the nurse and says, 'Cats eat birds. East now. Job is new. You father.' This speech pattern can be assessed as:
Correct Answer: C
Rationale: The correct answer is C: loose associations. This speech pattern is characteristic of loose associations seen in schizophrenia, where thoughts are disorganized and lack logical connections. The patient's statements lack coherence and jump from one topic to another without a clear link. Hyperverbosity (A) refers to excessive speech without a clear point, which is not evident in this scenario. Circumstantiality (B) involves excessive detail before reaching the main point, which is not present here. Expressing delusions (D) would involve holding false beliefs, which are not explicitly stated in the patient's speech.
Question 5 of 5
Drugs that treat individuals with schizophrenia interrupt neurotransmitter pathways in the brain, producing an effect throughout the entire nervous system that is:
Correct Answer: A
Rationale: The correct answer is A: Calming. Drugs used to treat schizophrenia often target neurotransmitter pathways to reduce symptoms like hallucinations and delusions. By regulating neurotransmitters like dopamine, these drugs help calm the individual's brain activity, leading to a reduction in psychotic symptoms. Choices B, C, and D are incorrect because drugs for schizophrenia are not intended to numb, satisfy, or stimulate the nervous system; rather, they aim to restore balance and alleviate distressing symptoms.