ATI RN
Health Care Utilization by Age Group Questions
Question 1 of 5
A patient with acute mania dances atop a pool table, waves a cue in one hand, and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to:
Correct Answer: B
Rationale: The correct answer is B because taking the patient to seclusion ensures safety for both the patient and others. This intervention controls the immediate risk of harm from the patient's unpredictable behavior. Telling the patient (choice A) may escalate the situation. Removing the patient from the pool table (choice C) may not address the underlying threat. Clearing the room of all other patients (choice D) is not the priority; ensuring immediate safety is paramount in this scenario.
Question 2 of 5
A client admitted with delusions, hallucinations, and thought disorder has the admitting diagnosis schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the client will:
Correct Answer: A
Rationale: Step 1: The client is admitted with symptoms suggestive of a psychotic disorder, specifically schizophreniform disorder. Step 2: The admitting diagnosis includes ruling out organic pathology, indicating a need to investigate potential physical causes. Step 3: An MRI test is a non-invasive imaging procedure that can help identify any structural abnormalities in the brain. Step 4: This test is appropriate in ruling out organic causes of the symptoms presented by the client. Step 5: Psychological testing (Choice B) is more focused on assessing cognitive and emotional functioning, not ruling out organic pathology. Step 6: Immunologic assay (Choice C) is used to detect antibodies or antigens in the blood, not typically relevant in this context. Step 7: Dexamethasone suppression test (Choice D) is used to assess for abnormalities related to cortisol levels in conditions like depression, not specific to ruling out organic pathology in psychotic disorders. Summary: Choice A is correct because an MRI test is the most relevant
Question 3 of 5
A client on an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
Correct Answer: D
Rationale: The correct answer is D: Hold the medication and call the client's doctor immediately. This is the correct course of action because the client is exhibiting signs of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications. Holding the medication is essential to prevent further complications. Calling the doctor is necessary to inform them of the situation and seek further instructions. Administering the medication (choice A) would exacerbate the symptoms, giving a lower dose (choice B) is not sufficient in this emergency situation, and administering an anticholinergic (choice C) is not the appropriate response for NMS.
Question 4 of 5
A patient moving from chair to chair in the day room and pacing in the hallway repeatedly, rapidly, and for extended periods is likely demonstrating ______, and the nurse should ______.
Correct Answer: C
Rationale: The correct answer is C: akathisia"¦administer PRN diphenhydramine (Benadryl) PO. Akathisia is characterized by restlessness and an inability to sit still. Administering diphenhydramine can help alleviate these symptoms. A is incorrect because dystonic reactions present with muscle spasms and abnormal postures, not restlessness. B is incorrect as anxiety does not typically manifest as physical restlessness. D is incorrect as tardive dyskinesia involves involuntary movements of the face and body, not restlessness.
Question 5 of 5
A patient is noted to be bending over backward in the group room. A peer asks what he is doing, and he replies, 'People say they are bending over backwards to help me, so I am bending over backwards to help myself.' This is an example of:
Correct Answer: B
Rationale: The correct answer is B: concrete thinking. Concrete thinking refers to interpreting things in a literal or straightforward manner without grasping abstract concepts or metaphors. In this scenario, the patient is taking the expression "bending over backward" literally, demonstrating a lack of understanding of its figurative meaning. A: Abstract thinking involves understanding complex concepts and interpreting information beyond the literal meaning. The patient's response does not demonstrate abstract thinking. C: Impaired reality testing refers to an inability to distinguish between what is real and what is not. The patient's response does not suggest a detachment from reality. D: Boundary impairment involves difficulty in recognizing and maintaining personal boundaries. The patient's response does not relate to boundary issues. In summary, the patient's literal interpretation of the expression "bending over backward" reflects concrete thinking, making choice B the correct answer.