ATI RN
Population Based Health Care Questions
Question 1 of 5
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence. 1. Disturbed thought processes: The patient's delusion of being plotted against by the physicians indicates impaired thought processes typical of paranoid schizophrenia. 2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violent acts towards others due to his paranoid beliefs. Summary of why other choices are incorrect: B: Spiritual distress and Social isolation are not primary concerns given the patient's acute symptoms of paranoia and risk for violence. C: Risk for loneliness and Knowledge deficit are not crucial at this point as the patient's primary issues are related to paranoia and violence. D: Disturbed personal identity and Nonadherence are not relevant to the immediate safety and mental health concerns presented by the patient.
Question 2 of 5
A patient with schizophrenia tells the nurse, 'Everyone must listen to me. I am the redeemer. I will bring peace to the world.' From this the nurse can determine that an appropriate nursing diagnosis is:
Correct Answer: C
Rationale: Step 1: The patient's statement indicates grandiosity and delusions of grandeur, common in schizophrenia. Step 2: Chronic low self-esteem is a common nursing diagnosis for those with grandiose delusions. Step 3: The patient's belief of being the redeemer suggests underlying feelings of inadequacy. Step 4: Addressing self-esteem can help the patient cope with such delusions. Summary: A is incorrect as there is no mention of auditory hallucinations. B is incorrect as there is no immediate threat of violence. D is incorrect as nonadherence to medication is not evident in the scenario.
Question 3 of 5
A useful strategy for helping a patient with schizophrenia manage a potential relapse is to:
Correct Answer: C
Rationale: The correct answer is C because teaching the patient and family about behaviors indicating an impending relapse helps in early detection and intervention. This empowers them to recognize warning signs like changes in behavior or mood, allowing for prompt action. Choice A (group therapy) may be beneficial for support but does not directly address relapse prevention. Choice B (medication adherence) is crucial but not specific to relapse management. Choice D (blood tests) is important for monitoring medication levels but does not focus on recognizing relapse indicators.
Question 4 of 5
A psychotic patient is delusional and has auditory hallucinations. The best statement to make when approaching the patient with an oral electronic thermometer would be:
Correct Answer: C
Rationale: The correct answer is C because it uses clear, simple language to explain the procedure to the patient. It acknowledges the patient's delusions by asking them to sit and calmly states the thermometer will be placed under their tongue. This approach is likely to minimize the patient's anxiety and increase cooperation. Option A is incorrect as it may cause the patient to feel apprehensive due to the mention of "hurt." Option B is incorrect because it does not provide specific instructions about the procedure, which may lead to confusion for the patient. Option D is incorrect as it does not address the patient's delusions or provide clear instructions, potentially leading to increased resistance from the patient.
Question 5 of 5
The client is describing her trip to town. She tells the nurse, 'I cold town yellow water girl outside below ground.' This speech disturbance is called:
Correct Answer: B
Rationale: The correct answer is B: Word salad. This speech disturbance is characterized by a jumble of words that lack coherent meaning or connection. In this case, the client's words are disorganized and nonsensical. Neologism (A) is the creation of new words, not a jumble of existing words. Flight of ideas (C) involves rapid shifts in thoughts without a clear connection, not a jumble of words. Verbigeration (D) is the constant repetition of words or phrases, not a jumble of unrelated words.