ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 of 5
A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them. The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, 'They're all plotting to destroy me. Isn't that true?' Which would be the most appropriate response?
Correct Answer: C
Rationale: The correct answer is C: Thinking that people want to destroy you must be very frightening. Rationale: 1. Acknowledges the patient's feelings: By stating that thinking people want to destroy him is frightening, the nurse shows empathy and validates his experience. 2. Validates the patient's emotions: This response does not directly agree or disagree but acknowledges the emotions behind the patient's statement. 3. Builds rapport: By showing understanding and empathy, the nurse can establish trust and rapport with the patient, leading to better communication and therapeutic relationship. Summary of other options: A: This response denies the patient's feelings and could potentially escalate the situation by invalidating his experiences. B: This response may come off as confrontational and does not address the patient's underlying fears. D: This response is dismissive and does not address the patient's emotional distress, potentially leading to further agitation.
Question 2 of 5
An 82-year-old widow with Alzheimer's disease lives with her daughter's family, which owns a catering business. During the week, the patient attends a day care center for patients with dementia. During the evenings, members of the family care for the patient. One day, the nurse at the day care center notices the patient's appearance is disheveled and that she startles easily. She has a strong odor of urine, and her hair is uncombed. When the nurse escorts the patient to the bathroom, she notices bruises on her wrists and back. What most likely explains the nurse's observations?
Correct Answer: A
Rationale: The correct answer is A: The patient is being neglected and abused within the family. The nurse's observations of the patient's disheveled appearance, strong odor of urine, uncombed hair, and bruises indicate signs of neglect and abuse. Here's the rationale: 1. Disheveled appearance and strong odor of urine suggest lack of personal care. 2. Uncombed hair signals neglect in grooming. 3. Bruises on wrists and back are indicative of physical abuse. 4. Startling easily may be due to fear or anxiety from abuse. In summary, the other choices (B, C, D) are incorrect because they do not account for the combination of neglect, poor hygiene, and physical injuries seen in the patient, which are more indicative of abuse and neglect within the family.
Question 3 of 5
After a person was abducted and raped at gunpoint by an unknown assailant, which assessment finding best indicates the acute phase of the rape-trauma syndrome?
Correct Answer: B
Rationale: The correct answer is B: Confusion and disbelief. During the acute phase of rape-trauma syndrome, the victim may experience feelings of confusion and disbelief as they try to process the traumatic event. This initial reaction is a common response to such a severe and violating experience. The victim may struggle to comprehend what has happened to them, leading to feelings of shock and disbelief. This phase is characterized by emotional numbing, disorientation, and difficulty in making decisions. Decreased motor activity (Choice A) is not specific to the acute phase of rape-trauma syndrome and can be a general response to trauma. Flashbacks and dreams (Choice C) are more commonly associated with the intrusion phase of the syndrome, which occurs after the acute phase. Fears and phobias (Choice D) may develop later in the reorganization phase of the syndrome as the victim tries to cope with the aftermath of the trauma.
Question 4 of 5
A victim of a sexual assault sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of:
Correct Answer: A
Rationale: The correct answer is A: The acute phase reaction. This behavior is characteristic of the immediate emotional response following a traumatic event like sexual assault. The victim may exhibit shock, disbelief, and emotional distress. In this scenario, the victim's reaction of disbelief and repetitive statements align with the acute phase reaction. The other options are incorrect because the angry stage (B) and delayed reaction (C) occur later in the trauma response process, while the long-term phase (D) reflects a more prolonged period of adjustment and coping.
Question 5 of 5
A nurse planning a group to help batterers learn more effective ways to cope would teach participants that the key component in wife battering is:
Correct Answer: A
Rationale: The correct answer is A: The need for the batterer to control. This is the key component in wife battering, as it is rooted in the batterer's desire to establish power and dominance over their partner. Teaching batterers more effective ways to cope involves addressing this underlying need for control. Explanation of other choices: B: Alcohol abuse by the batterer - While alcohol abuse may exacerbate violent behavior, it is not the primary cause of wife battering. C: History of psychotic behavior - Psychotic behavior may contribute to violence, but it is not the key component in wife battering. D: Failure of the woman to assert herself - Blaming the victim is not appropriate; the responsibility lies with the batterer's need for control.