ATI RN
Age Specific Care Questions
Question 1 of 5
A psychiatric technician mentions to the nurse, 'All these clients with Axis II problems! It makes me wonder how so many mothers could have been such poor parents and messed up their kids so badly!' The response by the nurse that helps put the development of personality disorders into perspective is:
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Personality disorders are complex conditions influenced by a combination of genetic, environmental, and biological factors. 2. Research has shown evidence suggesting a biological component in the development of personality disorders. 3. Understanding the biological component helps to destigmatize and provide a more comprehensive view of personality disorders. 4. This response helps the psychiatric technician understand that blaming parents solely is not accurate and that multiple factors contribute to the development of personality disorders. Summary: Choice C is correct because it highlights the importance of considering biological factors in the development of personality disorders, providing a more holistic perspective. Choices A, B, and D are incorrect as they do not address the multifactorial nature of personality disorders.
Question 2 of 5
A patient experiencing delirium secondary to corticosteroid toxicity is manifesting paranoid thinking and noisy, assaultive behavior. The patient is currently pacing the hall and shouting. A nurse has placed a call to the physician and is anticipating the following order:
Correct Answer: A
Rationale: The correct answer is A: the use of supervised restraints. In this situation, the patient is displaying agitated and assaultive behavior, posing a risk to themselves and others. Supervised restraints are necessary to ensure the safety of the patient and healthcare providers until the effects of corticosteroid toxicity subside. Restraints should only be used as a last resort when other interventions have failed. Choice B: A loading dose of phenytoin is incorrect because phenytoin is not indicated for managing delirium secondary to corticosteroid toxicity. Choice C: A small dose of prednisone is incorrect because adding more corticosteroids would exacerbate the toxicity and worsen the delirium. Choice D: An IV dose of thiamine is incorrect as thiamine is used to treat thiamine deficiency, not corticosteroid toxicity-induced delirium.
Question 3 of 5
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is 2.7 mg/dL. Which nursing diagnosis applies?
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia. Rationale: 1. Anorexia nervosa involves severe restriction of food intake, leading to significant weight loss and malnutrition. 2. The patient's history of virtually stopping eating and losing 25% of body weight aligns with the nursing diagnosis of imbalanced nutrition. 3. Hypokalemia (low serum potassium level) is common in patients with anorexia nervosa due to inadequate intake or purging behaviors. 4. The other choices are incorrect because they do not match the patient's specific presentation of anorexia nervosa and hypokalemia.
Question 4 of 5
A nursing intervention that will be planned to occur early in the nurse-patient relationship with a client with an eating disorder is:
Correct Answer: A
Rationale: The correct answer is A: formulating a nurse-client contract. This intervention is essential early in the nurse-patient relationship with a client with an eating disorder because it establishes clear boundaries, roles, and expectations. By creating a contract, both the nurse and the client can communicate openly about their goals, responsibilities, and treatment plan. This helps build trust, promotes collaboration, and provides a framework for the therapeutic relationship. Choices B, C, and D are incorrect: B: Using confrontation to attack denial may be counterproductive and harmful in the early stages of the relationship as it can lead to resistance and damage trust. C: Placing the client in a therapeutic group may be beneficial at a later stage but not necessarily an appropriate early intervention when individual needs should be addressed first. D: Attacking enmeshment by separating client and family is not a suitable early intervention as it may cause distress and disrupt important support systems.
Question 5 of 5
A client with an eating disorder that has resulted in weight loss to a point 15% below normal weight tells the nurse, 'I don't need to be hospitalized. I can control myself.' The nurse continues to prepare the client for hospitalization because the vicious cycle of eating disorder behavior is fueled by:
Correct Answer: A
Rationale: The correct answer is A: feelings of power and control resulting from weight loss. In clients with eating disorders, the behavior is often driven by a sense of control and power gained through weight loss. This reinforces the cycle of the disorder as the individual feels empowered by their ability to restrict food intake. This false sense of control becomes a driving force in the continuation of the disorder. Incorrect answers: B: Dysfunctional family dynamics may contribute to the development of an eating disorder, but in this scenario, the client's refusal for hospitalization is more related to their own sense of control rather than family dynamics. C: Faulty use of the defense mechanism projection is not the primary reason for the client's resistance to hospitalization in this case. D: Lack of superego constraints on behavior is not the main factor driving the client's refusal for hospitalization.