ATI RN
Core Concepts of Family Centered Care Questions
Question 1 of 5
A patient who has AIDS has been instructed on foods to eat to reduce the risk of infection. Which foods should the patient select that indicates correct understanding of this teaching? (Select all that apply.)
Correct Answer: D
Rationale: The correct answer is D: Pasteurized milk. This is because pasteurization kills harmful bacteria, making it safe for consumption by individuals with weakened immune systems like AIDS patients. A: Rare meat and B: Raw seafood may contain harmful bacteria that can pose a risk of infection for AIDS patients. C: Soft egg yolks may also contain harmful bacteria if not fully cooked, which can be dangerous for individuals with compromised immune systems. In summary, pasteurized milk is the safest option as it eliminates the risk of bacterial contamination, while the other choices may increase the risk of infection for a patient with AIDS.
Question 2 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 3 of 5
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient:
Correct Answer: B
Rationale: The correct answer is B: the patient has a high tolerance to alcohol. At a blood alcohol level of 400 mg/dl, most individuals would exhibit severe symptoms such as unconsciousness or coma. However, this patient only shows mild symptoms of ataxia, slurred speech, and confusion, indicating a high tolerance to alcohol. This high tolerance suggests that the patient regularly consumes large amounts of alcohol, leading to an adaptation in the body's response to alcohol. Choice A is incorrect because a blood alcohol level of 400 mg/dl is indicative of significant alcohol consumption, contradicting the statement that the patient rarely drinks alcohol. Choice C is incorrect as disulfiram is used to treat alcohol dependence, not tolerance. Choice D is incorrect since sedative drugs would exacerbate the effects of alcohol, causing more severe symptoms than what is observed in this case.
Question 4 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 5 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.