ATI RN
Population Specific Care Questions
Question 1 of 5
A patient with anorexia nervosa is treated as an outpatient. Select the desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:
Correct Answer: A
Rationale: The correct answer is A: Gain 1 to 2 pounds. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). In anorexia nervosa, gaining weight is crucial for recovery. Weight gain indicates improved nutritional status and overall health. Option B is incorrect as excessive exercise can exacerbate the patient's condition. Option C is incorrect as laxative use is not a recommended treatment for anorexia nervosa. Option D is incorrect as self-weighing may lead to obsessive behavior in patients with eating disorders.
Question 2 of 5
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
Question 3 of 5
The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?
Correct Answer: B
Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline. Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms. Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome. Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome. Summary: - Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome. - Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention. - Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.
Question 4 of 5
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _____, and the nurse should _____.
Correct Answer: A
Rationale: The correct answer is A: A dystonic reaction"¦administer PRN IM benztropine (Cogentin). This patient is exhibiting symptoms of acute dystonia, a extrapyramidal side effect of haloperidol. Dystonic reactions are characterized by sustained muscle contractions causing abnormal postures. Benztropine is an anticholinergic medication that helps alleviate these symptoms by blocking the neurotransmitter acetylcholine. Administering benztropine is the appropriate treatment for acute dystonia. Summary of other choices: B: Tardive dyskinesia"¦seek a change in the drug or its dosage - Tardive dyskinesia is a side effect that occurs after long-term antipsychotic use, not acutely like in this case. C: Waxy flexibility"¦continue treatment with antipsychotic drugs - Waxy flexibility is a symptom of catatonia, not a side effect of antipsychotic medications
Question 5 of 5
A 32-year-old client with an admitting diagnosis of catatonic schizophrenia has been mute and motionless for 2 days. The priority nursing diagnosis is:
Correct Answer: A
Rationale: The correct answer is A: Risk for deficient fluid volume. The priority nursing diagnosis in this case is to address the client's physical needs to ensure their safety and well-being. The client's mutism and immobility put them at risk for dehydration and malnutrition. By prioritizing the risk for deficient fluid volume, the nurse can address the immediate physiological needs of the client. Choice B: Impaired physical mobility is incorrect because while the client is motionless, the immediate concern is addressing the risk of dehydration. Choice C: Impaired social interaction is incorrect as addressing social interaction is not the priority when the client's physical needs are not being met. Choice D: Ineffective coping is incorrect because the client's presentation is indicative of a more urgent physical need for hydration and nutrition.