ATI RN
Age Specific Populations Questions
Question 1 of 5
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response.
Correct Answer: A
Rationale: The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety. Summary of other choices: B: This response minimizes the victim's feelings and does not address the seriousness of the situation. C: This response ignores the victim's emotional distress and does not address the potential for self-harm. D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
Question 2 of 5
A client tells the nurse he has just finished an important business meeting, when in fact he has been napping. Upon what rationale should the nurse's response be based?
Correct Answer: C
Rationale: The correct answer is C because reinforcing reality helps the client maintain maximum functioning. By gently guiding the client back to reality, the nurse can support their cognitive abilities and prevent further confusion or disorientation. Choice A is incorrect because ignoring memory deficits does not address the issue at hand. Choice B is incorrect as confronting delusions may lead to increased distress. Choice D is incorrect as it does not address the situation effectively and may not help the client maintain cognitive functioning.
Question 3 of 5
An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. The nurse hearing this history will identify the history and symptoms as pointing to:
Correct Answer: A
Rationale: The correct answer is A: Delirium related to drug toxicity. The client's sudden onset of visual hallucinations, fear, agitation, recent medication changes, and pacing behavior are indicative of delirium. Delirium is an acute change in mental status characterized by confusion, disorientation, and perceptual disturbances, often triggered by medication changes in the elderly. Pick's disease (B) is a type of frontotemporal dementia characterized by personality changes and language difficulties. Parkinson's dementia (C) is a type of dementia associated with Parkinson's disease, presenting with motor symptoms first. Amnestic disorder (D) is a memory impairment disorder, not consistent with the client's symptoms.
Question 4 of 5
A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse's first action should be to:
Correct Answer: A
Rationale: The correct answer is A: Take the client's vital signs. The first step in assessing any client in the emergency department is to ensure their physiological stability. Vital signs provide essential information about the client's current physical condition, such as heart rate, blood pressure, respiratory rate, and temperature. In this case, the client's alternating states of hyperalertness and difficulty in arousal, disorientation, confusion, agitation, memory impairment, delusions, and misinterpretations of surroundings indicate a potential medical emergency. Therefore, taking the client's vital signs is crucial to determine if there are any immediate life-threatening conditions that need to be addressed promptly. Summary of other choices: B: Restrain the client to prevent injury - Restraint should only be used as a last resort for safety concerns and after assessing the client's physical condition. C: Obtain a PRN order for a psychotropic medication - Administering psychotropic medication should not be the first action without assessing the client's physical condition and
Question 5 of 5
The nurse is aware, when developing a care plan, that the three major goals of care for the client in whom Alzheimer's disease has been diagnosed include providing for the client's safety and well-being, therapeutically managing the client's behaviors, and:
Correct Answer: B
Rationale: The correct answer is B: Providing support for family, relatives, and caregivers. This is because Alzheimer's disease not only affects the individual but also has a significant impact on their family and caregivers. Providing support to them is crucial for maintaining the overall well-being of the client. Choice A is incorrect as Alzheimer's disease does not have a curative treatment. Choice C is incorrect as nursing home placement is not always necessary and should be considered as a last resort. Choice D is incorrect as tracking medical, legal, and financial records is important but not a major goal in the care plan for Alzheimer's clients. Supporting the family and caregivers helps in creating a supportive environment for the client and ensures holistic care.