ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 of 5
A patient with acute mania approaches the nurse, waves a newspaper, and says, "I want the phone right now. I need to call this store while their sale is going on. I need ten dresses and four pairs of shoes." Select the nurse's best intervention.
Correct Answer: C
Rationale: The correct answer is C because the patient's behavior is impulsive and reflects poor judgment, which are common symptoms of acute mania. By telling the patient that phone use is not allowed until self-control is improved, the nurse is setting a boundary to prevent further impulsive actions. This intervention prioritizes safety and helps maintain a therapeutic environment. A: This option does not address the immediate need to manage the patient's impulsive behavior and may put the friend in a potentially risky situation. B: Inviting the patient to look at fashion magazines does not address the impulsivity and may even reinforce the behavior. D: Asking about the patient's financial situation is not the most appropriate intervention at this time.
Question 2 of 5
A client has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another client a 'jerk' without provocation. The nurse asks the client how he is feeling, and he responds, 'Everybody picks on me. They frobitz me.' The nurse would assess 'frobitz' as:
Correct Answer: D
Rationale: The correct answer is D: A neologism. A neologism is a newly coined word or expression that is not easily understood by others. In this case, the client's use of the word 'frobitz' is not a recognized word, indicating it may be a neologism. This is commonly seen in individuals with schizophrenia who create new words or distort existing ones. A: Circumstantial speech involves excessive and unnecessary details before reaching the main point. The client's response is not characterized by this. B: Loose associations involve a lack of logical connections between thoughts. The client's response is not demonstrating this. C: Evidence of delusional thinking would involve fixed, false beliefs that are not based in reality. The client's use of 'frobitz' does not necessarily indicate a delusion. In summary, the use of 'frobitz' by the client is indicative of a neologism, as it is a new and potentially meaningless
Question 3 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 4 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 5 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.