ATI RN
Concepts of Family Health Care Questions
Question 1 of 5
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is:
Correct Answer: D
Rationale: The correct answer is D because alcohol consumption during pregnancy can lead to fetal alcohol syndrome (FAS), characterized by microcephaly and cognitive impairments. Alcohol can cross the placental barrier, affecting the developing fetus's brain and causing irreversible damage. Jaundice (choice A) is not directly caused by alcohol consumption but by other factors like liver dysfunction. Dependence on alcohol (choice B) is a consequence for the mother, not the baby. Although alcohol can lead to low birth weight, the term "underweight" (choice C) is not specific enough to capture the full extent of harm caused by prenatal alcohol exposure.
Question 2 of 5
The treatment team plans care for a person diagnosed with paranoid schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Dual diagnosis: Simultaneous treatment is crucial as both conditions impact each other. 2. Cannabis withdrawal may worsen schizophrenia symptoms, so treating both concurrently is essential. 3. Addressing both diagnoses concurrently increases treatment effectiveness. 4. Residential treatment may not be necessary at this stage without considering simultaneous treatment. Summary: B: Residential treatment may not be needed immediately; focus on simultaneous treatment. C: Withdrawal may worsen schizophrenia symptoms; treating both conditions concurrently is preferable. D: Treating schizophrenia first may not address the immediate exacerbation of symptoms due to cannabis use.
Question 3 of 5
In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
Correct Answer: A
Rationale: The correct answer is A because stabilizing the patient's vital signs is the top priority in this critical situation. A blood pressure of 66/40 mm Hg indicates severe hypotension, which can lead to organ failure. A pulse of 140 bpm and shallow respirations of 8 bpm indicate poor perfusion and respiratory distress. Achieving a BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 bpm indicates improved perfusion and oxygenation, which are crucial for the patient's survival. Option B is incorrect as achieving a drug-free state is not the immediate priority in an overdose situation. Option C is incorrect as attending Narcotics Anonymous meetings is important for long-term recovery but not the immediate priority. Option D is incorrect as identifying community resources for substance abuse treatment is important but not as critical as stabilizing the vital signs in an overdose situation.
Question 4 of 5
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
Correct Answer: D
Rationale: The correct answer is D because observing for depression and suicidal ideation is crucial when caring for a patient withdrawing from CNS stimulants. Depression and suicidal ideation are common withdrawal symptoms, so monitoring for these signs is essential for the patient's safety. It allows for early intervention and appropriate support to prevent any harm. Choice A is incorrect as frequent physical contact may not be appropriate and can potentially agitate the patient during withdrawal. Choice B is incorrect as intellectual activities requiring concentration may overwhelm the patient who is already going through withdrawal symptoms. Choice C is incorrect as denying the patient's requests can lead to increased agitation and resistance during withdrawal, which is not conducive to effective care.
Question 5 of 5
An adult in the emergency department states, 'I feel restless. Everything I look at wavers. Sometimes I’m outside my body looking at myself. I hear colors. I think I’m losing my mind.' Vital signs are slightly elevated. The nurse should suspect a(n):
Correct Answer: D
Rationale: The correct answer is D, D-lysergic acid diethylamide (LSD) ingestion. LSD causes visual disturbances, dissociation, heightened sensory perceptions, and altered sense of reality, matching the client's symptoms. Vital signs being slightly elevated are consistent with LSD use. Schizophrenic episodes (A) involve long-term symptoms, not acute onset. Cocaine overdose (B) would present with more severe vital sign changes. PCP intoxication (C) typically causes aggression and hallucinations, not the described symptoms.