ATI RN
Core Concepts of Family Centered Care Questions
Question 1 of 5
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, 'Bugs are crawling on my bed. I’ve got to get out of here.' What is the most accurate assessment of the situation? The patient:
Correct Answer: C
Rationale: The correct answer is C: The patient has symptoms of alcohol withdrawal delirium. The presentation of shakiness, irritability, anxiety, diaphoresis, elevated heart rate, and hallucinations ('bugs are crawling on my bed') are classic signs of alcohol withdrawal delirium. Delirium tremens, a severe form of alcohol withdrawal, typically occurs 48-72 hours after the last drink and can be life-threatening. This patient's symptoms are consistent with the timeline and manifestations of alcohol withdrawal, requiring immediate medical intervention. Incorrect answers: A: Manipulating staff for attention is unlikely given the severity of the symptoms and the potential life-threatening nature of alcohol withdrawal delirium. B: Head injury would not typically present with these specific symptoms and timeline. D: Acute psychosis would not typically manifest with these specific symptoms in the context of alcohol intoxication and withdrawal.
Question 2 of 5
A patient comes to an outpatient appointment obviously intoxicated. The nurse should:
Correct Answer: D
Rationale: Step-by-step rationale for Answer D (Correct): 1. Safety first: Intoxicated patients can be a safety risk to themselves and others. 2. Ethical responsibility: Providing care to an intoxicated patient may compromise the quality of care. 3. Setting boundaries: Communicating that the appointment cannot proceed due to intoxication sets a clear boundary. 4. Referral assistance: The patient can be directed to appropriate resources for help with substance abuse. Summary of why other choices are incorrect: A (explore reasons): Not appropriate when patient is intoxicated. B (inpatient unit): Premature without assessing the situation. C (detox unit): Immediate detox may not be necessary.
Question 3 of 5
A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse’s drug use was evident?
Correct Answer: B
Rationale: The correct answer is B: Seeking to be assigned as the medication nurse. This behavior is an early indicator of drug use because it provides the nurse with easier access to narcotics, which they may be seeking for self-use. By actively seeking out this responsibility, the nurse may have ulterior motives related to drug diversion. Choice A is incorrect because accepting responsibility for medication errors is a common behavior among healthcare professionals and does not necessarily indicate drug use. Choice C, frequent complaints of physical pain, is also incorrect as it could be related to various health issues and not specifically drug use. Choice D, high sociability with peers, is not a direct indicator of drug use and does not provide any evidence of potential drug diversion.
Question 4 of 5
A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
Correct Answer: C
Rationale: The correct answer is C: Substance dependence. This scenario describes a pattern of symptoms indicative of substance dependence, which includes tolerance, withdrawal symptoms when trying to cut back, unsuccessful attempts to quit, and continued use despite negative consequences. The patient's reliance on cigarettes to manage anxiety, craving, poor concentration, and headache indicates a psychological and physical dependence on nicotine. A: Substance abuse typically involves harmful use of a substance but does not necessarily include physiological dependence. B: Substance intoxication refers to the immediate effects of a substance in the body, not the long-term pattern of dependence. D: Recreational use of a social drug implies occasional and non-regular use, which does not align with the described scenario of chronic, daily smoking leading to withdrawal symptoms.
Question 5 of 5
When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect:
Correct Answer: D
Rationale: The correct answer is D: anterograde amnesia. Flunitrazepam is a benzodiazepine known for causing memory loss, specifically anterograde amnesia, where the person has difficulty forming new memories after ingestion. This is due to the drug's effects on the hippocampus and frontal cortex. Acrophobia (fear of heights), hypothermia, and hallucinations are not typically associated with flunitrazepam ingestion. Therefore, D is the expected outcome when assessing a patient who has ingested flunitrazepam.