ATI RN
Concept of Family Centered Care Questions
Question 1 of 5
A patient who has AIDS expresses concern about telling others about the illness. Which response would be appropriate by the nurse?
Correct Answer: B
Rationale: The correct answer is B: "You should tell those who have a reason to know." This response is appropriate as it respects the patient's autonomy and privacy. By sharing the diagnosis with only those who need to know, the patient can control who has access to this sensitive information. This approach also promotes trust and open communication within the patient's support network. Option A is incorrect as it disregards the patient's right to privacy and may cause unnecessary stress. Option C is incorrect as it assumes the diagnosis will inevitably become public, which may not be the case if the patient chooses to keep it private. Option D is incorrect as it oversimplifies the situation and may not consider the patient's unique circumstances and preferences.
Question 2 of 5
A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient?
Correct Answer: D
Rationale: The correct answer is D: Risk for Infection due to weak immune system and parenteral therapy. This is the priority nursing diagnosis because a patient with AIDS-related wasting syndrome is at high risk for infections due to their weak immune system and parenteral therapy, which can introduce pathogens into the body. Addressing the risk for infection is crucial in preventing further complications and promoting the patient's overall well-being. Choice A (Pain related to immobility) is not the priority as the patient's immobility is not the immediate concern compared to the risk of infection. Choice B (Ineffective Individual Coping due to terminal stage of HIV) may be a valid concern, but ensuring the patient's physical health and preventing infections take precedence. Choice C (Risk for Injury due to impaired mobility, weakness, and weight loss) is important but does not address the immediate threat of infection that the patient faces.
Question 3 of 5
The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient?
Correct Answer: D
Rationale: The correct answer is D (5 mm) for a positive Mantoux test in a patient with HIV. In HIV-positive individuals, a positive test is considered when the induration is ≥5 mm. This is because the immune system may be compromised, leading to a delayed immune response. Choices A, B, and C (2 mm, 3 mm, 4 mm) are not considered positive for HIV-positive individuals due to their weakened immune system, requiring a larger induration size to indicate a positive test.
Question 4 of 5
The nurse is preparing to provide education related to HIV transmission at a local community health fair. Which statements should the nurse recommend for inclusion in the teaching? (Select all that apply.)
Correct Answer: B
Rationale: Step 1: Using a new condom for each sex act helps reduce the risk of HIV transmission by preventing the exchange of bodily fluids. Step 2: This practice ensures that there is no risk of contamination from a previously used condom. Step 3: It is a crucial aspect of safe sex practices to protect oneself and others from contracting HIV. Summary: Choice B is correct as it promotes safe sex practices. Choices A, C, and D are incorrect as they do not contribute to reducing the risk of HIV transmission.
Question 5 of 5
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, 'Somebody tied me up with ropes.' The patient is experiencing:
Correct Answer: A
Rationale: The correct answer is A: illusion. An illusion is a misinterpretation of a real external stimulus. In this case, the patient is misperceiving the traction as ropes due to the altered mental state from intoxication. It is a sensory distortion based on a real object. Delusion (B) is a fixed false belief, not related to sensory perceptions. Hallucinations (C) are false sensory perceptions without external stimulus. Hypnagogic phenomenon (D) refers to sensory experiences during the transition from wakefulness to sleep, not applicable here.