ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 of 5
A patient who takes lithium phones the nurse at the clinic to say, "I've had diarrhea for 4 days. I feel weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" Which instruction by the nurse is appropriate?
Correct Answer: A
Rationale: The correct answer is A: Have someone bring you to the clinic immediately. The patient is experiencing symptoms of lithium toxicity, including diarrhea, weakness, unsteadiness, and worsening hand tremor. These symptoms indicate a potential lithium overdose, which can be life-threatening. Bringing the patient to the clinic immediately is crucial for assessment, monitoring, and intervention. Choice B is incorrect because restricting food and fluids can worsen dehydration and electrolyte imbalances. Choice C is incorrect as adding salt to water can exacerbate electrolyte abnormalities in lithium toxicity. Choice D is incorrect as taking antidiarrheal medication can further worsen the symptoms and delay appropriate medical treatment.
Question 2 of 5
In planning aftercare for a client with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the client to have stimulation, structure, socialization, and support. Which option would best incorporate these factors?
Correct Answer: B
Rationale: The correct answer is B: Attending a psychosocial club. This option best incorporates the necessary factors of stimulation, structure, socialization, and support for the client with schizophrenia. - Stimulation: Psychosocial clubs offer various activities to engage the client's mind and keep them occupied. - Structure: These clubs usually have regular schedules and routines, providing the client with a sense of order and predictability. - Socialization: Interacting with others in the club can help the client improve social skills and combat feelings of isolation. - Support: Being part of a community in the club can provide emotional support and encouragement for the client. Incorrect Choices: - A: Day hospitalization may offer structure and support but may lack the socialization and stimulation provided by a psychosocial club. - C: Living with his elderly mother may provide support but may not offer the necessary stimulation, structure, and socialization outside of the home environment. - D: Spending free time in the mall may offer
Question 3 of 5
The nurse is assessing a client who will be having an orthopedic surgery. The client takes an antipsychotic medication and shares that he has recently started using two herbal preparations for his nerves. The nurse should:
Correct Answer: A
Rationale: Rationale: A: Asking for the specific names of the herbal compounds is important to assess potential interactions with the antipsychotic medication. B: Ignoring the herbal compounds could lead to adverse effects or interactions during surgery. C: Telling him to stop may not be appropriate without knowing the specific compounds and their effects. D: Discussing the physician's viewpoint is not as crucial as gathering information on potential interactions.
Question 4 of 5
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale. 1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine. 2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia. 3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia. 4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described. 5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned. 6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.
Question 5 of 5
A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.