ATI RN
Core Concepts of Family Centered Care Questions
Question 1 of 5
A patient with AIDS is prescribed the nucleoside reverse transcriptase inhibitor lamivudine (Epivir). What information should the nurse ensure that the patient receives about this medication? (Select all that apply.)
Correct Answer: B
Rationale: Step 1: Lamivudine (Epivir) can cause hepatotoxicity, leading to yellowing of the skin (jaundice). Step 2: Yellowing of the skin is a serious side effect that should be reported immediately to prevent further liver damage. Step 3: Reporting yellowing of the skin promptly allows for timely evaluation and necessary interventions. Summary: Reporting bleeding, change in urine output, or flu-like symptoms are not specific to lamivudine and are not directly related to its side effects. Yellowing of the skin is a critical side effect that requires immediate attention.
Question 2 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 3 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 4 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.
Question 5 of 5
A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe?
Correct Answer: C
Rationale: The correct answer is C: Substance dependence. This scenario describes a pattern of symptoms indicative of substance dependence, which includes tolerance, withdrawal symptoms when trying to cut back, unsuccessful attempts to quit, and continued use despite negative consequences. The patient's reliance on cigarettes to manage anxiety, craving, poor concentration, and headache indicates a psychological and physical dependence on nicotine. A: Substance abuse typically involves harmful use of a substance but does not necessarily include physiological dependence. B: Substance intoxication refers to the immediate effects of a substance in the body, not the long-term pattern of dependence. D: Recreational use of a social drug implies occasional and non-regular use, which does not align with the described scenario of chronic, daily smoking leading to withdrawal symptoms.