ATI RN
Health Care Utilization by Age Group Questions
Question 1 of 5
A woman, abducted and raped at gunpoint by an unknown assailant, was found confused and disoriented. The nurse makes these observations about the patient: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the patient's level of anxiety?
Correct Answer: D
Rationale: The correct answer is D: Severe. The patient's symptoms of talking rapidly, inability to concentrate, and indecisiveness are indicative of severe anxiety. Rapid speech and disjointed phrases suggest heightened arousal, while the inability to concentrate and make decisions point to severe impairment in cognitive functioning. These symptoms align with the DSM-5 criteria for severe anxiety, which includes extreme levels of distress and impairment in daily functioning. Weak (A), mild (B), and moderate (C) levels of anxiety would not typically manifest in such severe cognitive and behavioral symptoms.
Question 2 of 5
A client, age 70, was brought into the Emergency Department by family members who reported a fall. During the assessment the nurse became suspicious that the client had suffered physical abuse. The client denied that she had been abused. Her denial is most likely based on her:
Correct Answer: B
Rationale: The correct answer is B: Fear of the possibility of being removed from her family. This is because elderly individuals who are experiencing abuse may fear being separated from their family if they disclose the abuse. This fear of losing their support system can lead them to deny or minimize the abuse. This choice is the most likely reason for the client's denial in this scenario. Choice A: Strong belief that nothing could be done to help her is incorrect because the client's denial is not based on a belief that nothing could be done, but rather on a fear of being removed from her family. Choice C: Feeling that she deserved the physical abuse is incorrect as victims of abuse often do not feel they deserve the abuse, but rather may feel ashamed or fearful. Choice D: Lack of trust that the situation could be changed is incorrect because the client's denial is more likely based on a fear of losing her family, rather than a lack of trust in the situation changing.
Question 3 of 5
A new nurse asks the experienced nurse who is caring for a battered woman client, 'Why did you ask about culture when it was obvious you needed to focus on the battering?' The experienced nurse should respond:
Correct Answer: C
Rationale: Rationale: - Choice C is correct because culture influences how individuals perceive and respond to violence, impacting their help-seeking behaviors and coping mechanisms. - Understanding the client's cultural background is crucial for providing appropriate care and support. - Choices A, B, and D are incorrect as they do not address the importance of considering culture in understanding and addressing domestic violence in this context.
Question 4 of 5
A client has been diagnosed with a dementia secondary to cerebral disease. The family members note the client 'has not been as sharp as he once was' and that he has developed urinary incontinence and a gait disturbance. They attributed the first symptom to normal aging but were alarmed by the latter two symptoms. Based on this history, which of the following should come to mind?
Correct Answer: A
Rationale: Step 1: The client presents with urinary incontinence and a gait disturbance, suggestive of normal pressure hydrocephalus (NPH) due to cerebral disease. Step 2: NPH is characterized by the triad of cognitive decline, gait disturbances, and urinary incontinence. Step 3: Symptoms of NPH can mimic normal aging but are distinct from other conditions. Step 4: Vitamin B12 deficiency (B) primarily presents with anemia and neurological symptoms, not the triad seen in NPH. Step 5: Hepatic disease (C) typically presents with symptoms related to liver dysfunction, not the triad of NPH. Step 6: Tuberculosis (D) manifests with respiratory symptoms and constitutional symptoms, not the cognitive decline and gait issues seen in NPH.
Question 5 of 5
The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
Correct Answer: B
Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.