ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
A student transfers from a hometown college to a university 200 miles away after breaking up with her boyfriend of 2 years. She was slow to make friends at the university. The history shows a close relationship with her mother and sister. She began eating large quantities when she felt sad, and then she induced vomiting. When the student's schoolwork declined, she sought help from the university health clinic. During the initial interview, what priority issue should the nurse address?
Correct Answer: A
Rationale: The correct answer, Losses (choice A), should be the priority issue for the nurse to address during the initial interview with the student. The rationale is as follows: 1. **Emotional Impact of Breakup**: The student's recent breakup is a significant loss that can trigger emotional distress. 2. **Social Isolation**: Slow to make friends at the university could indicate feelings of loneliness and isolation, further exacerbating the impact of the breakup. 3. **Eating Disorder Behaviors**: Eating large quantities and inducing vomiting are maladaptive coping mechanisms linked to emotional distress and loss. 4. **Academic Decline**: The decline in schoolwork could be a manifestation of the student's emotional struggles related to loss. 5. **Relationship with Family**: Close relationship with her mother and sister may also influence how she copes with losses and seeks support. Summary: - **Sleep Patterns (choice B)**: While important, sleep patterns are secondary to addressing the student's emotional distress and coping mechanisms related
Question 2 of 5
A depressed patient who is taking a tricyclic antidepressant tells the nurse, "I don't think I can keep taking these pills. They make me very dizzy, especially when I stand up." The best nursing response is:
Correct Answer: B
Rationale: The correct answer is B because tricyclic antidepressants can cause orthostatic hypotension leading to dizziness upon standing. Advising the patient to drink more fluids and change positions slowly can help alleviate this symptom. Choice A minimizes the patient's concern, which is not therapeutic. Choice C diminishes the patient's experience and feelings. Choice D dismisses the patient's symptoms and attributes them solely to the patient's negative thinking, which is not appropriate.
Question 3 of 5
A patient with bipolar disorder, mania, relapsed after discontinuing lithium. The health care provider prescribes lithium 600 mg BID and olanzapine (Zyprexa) 10 mg BID. What is the rationale for addition of olanzapine to the lithium regime? It will:
Correct Answer: B
Rationale: The correct answer is B: Bring hyperactivity under rapid control. Rationale: 1. Olanzapine is an atypical antipsychotic known for its rapid onset of action in controlling manic symptoms, including hyperactivity. 2. Lithium alone may take time to reach therapeutic levels and show efficacy, while olanzapine can provide more immediate relief. 3. Combining olanzapine with lithium can address acute manic symptoms effectively and quickly. 4. Choice A is incorrect because olanzapine does not specifically minimize lithium's side effects. 5. Choice C is incorrect as olanzapine does not directly potentiate lithium's antimanic action. 6. Choice D is incorrect because olanzapine is typically used for acute symptom management rather than long-term control.
Question 4 of 5
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect _____ and should _____.
Correct Answer: A
Rationale: The correct answer is A: Neuroleptic malignant syndrome. The patient is exhibiting symptoms consistent with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, elevated temperature, and vital sign changes are classic signs of NMS. Treatment includes immediate cooling to lower the body temperature and transfer to the intensive care unit for close monitoring and supportive care. Choice B: Anticholinergic toxicity does not fit the patient's presentation as there are no specific signs of anticholinergic toxicity such as dry mucous membranes, dilated pupils, or tachycardia. Choice C: Relapse of psychosis is unlikely to present with the same constellation of symptoms, including altered mental status, fever, and vital sign changes. Choice D: Agranulocytosis is characterized by a severe drop in white blood cells, leading to increased risk of infection, but it does
Question 5 of 5
A client displays disorganized thinking, difficult-to-follow speech, and silly, inappropriate affect. The client isolates himself from other clients and staff, ignores unit activities, and often seems to be listening and responding to unseen stimuli. This client's behavior most closely conforms to the characteristic behavior of:
Correct Answer: D
Rationale: The correct answer is D: Disorganized schizophrenia. The client's symptoms of disorganized thinking, difficult-to-follow speech, inappropriate affect, social withdrawal, and hallucinations (responding to unseen stimuli) align with the diagnostic criteria for Disorganized Schizophrenia. This subtype is characterized by disorganized behavior, speech, and affect, as well as social withdrawal and hallucinations. A: Residual schizophrenia does not involve active psychotic symptoms like hallucinations or delusions, which are present in the client's behavior described. B: Schizoaffective disorder combines symptoms of schizophrenia and mood disorders, and the client's symptoms do not strongly suggest a mood disorder component. C: Paranoid schizophrenia typically involves prominent delusions and auditory hallucinations, which are not emphasized in the client's behavior described.