ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 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 2 of 5
The experienced nurse assessing a battered woman client uses many open-ended questions during the interview. The rationale for this is that:
Correct Answer: A
Rationale: The correct answer is A because using open-ended questions allows the client to express themselves freely, promoting a sense of control and empowerment. This approach helps build trust and rapport, enabling the client to share their experiences more openly. Choice B is incorrect because closed-ended questions limit the client's ability to fully express themselves. Choice C is incorrect as open-ended questions encourage deeper reflection and discussion, which may not be easily understood by anxious individuals. Choice D is incorrect because while clients can refuse to answer sensitive questions, open-ended questions actually encourage them to share more, rather than withhold information.
Question 3 of 5
When the family of a client who has been diagnosed with a dementia secondary to normal pressure hydrocephalus asks the nurse about prognosis, the nurse should reply:
Correct Answer: C
Rationale: The correct answer is C because normal pressure hydrocephalus (NPH) symptoms typically improve after a shunt is inserted to drain the excess cerebrospinal fluid, leading to a better prognosis. This intervention can help alleviate symptoms such as gait disturbances, cognitive impairment, and urinary incontinence associated with NPH. Choice A is incorrect as it inaccurately states that the prognosis is inevitably poor, which is not true for NPH with appropriate treatment. Choice B is incorrect because NPH symptoms can be effectively managed with treatment, so it is not accurate to say that there will always be good and bad days for the rest of the client's life. Choice D is incorrect as it does not provide specific information about the positive impact of shunt insertion on NPH symptoms and prognosis.
Question 4 of 5
A client with dementia was admitted to a dementia unit after she began persistently wandering away from home. The nursing staff should plan to:
Correct Answer: D
Rationale: The correct answer is D because providing the client with an electronic alarm that sounds when she nears the exit door is the best option to ensure her safety. This approach allows for monitoring without restricting her movement excessively. Choice A is incorrect as unlimited freedom poses risks. Choice B is not practical or feasible long-term. Choice C is not person-centered and may lead to discomfort and agitation. The electronic alarm in choice D is the most effective and least intrusive method to prevent wandering while respecting the client's autonomy.
Question 5 of 5
The early stage of Alzheimer's disease is characterized by:
Correct Answer: A
Rationale: The correct answer is A: Loss of recent memory. In the early stage of Alzheimer's disease, individuals typically experience difficulty remembering recent events, conversations, or information. This is due to the initial impact of the disease on the hippocampus and other brain regions responsible for forming new memories. Choices B, C, and D are incorrect because loss of remote memory (choice B) usually occurs in later stages, withdrawal from family (choice C) can be a result of various factors beyond memory loss, and apraxia (choice D) refers to the inability to perform coordinated movements and is not a primary symptom of early-stage Alzheimer's.