ATI RN
Age Specific Patient Care Questions
Question 1 of 5
An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which indicator would suggest that nursing interventions are succeeding?
Correct Answer: A
Rationale: The correct answer is A because regular school attendance indicates the child's improved well-being and ability to prioritize education over caregiving responsibilities. B: Playing calmly does not necessarily indicate overall improvement in the child's situation. C: The father's silence during nurse visits does not directly reflect the child's well-being or progress. D: The mother correcting negative comments by the child is positive but does not directly address the child's caregiving responsibilities or self-perceptions.
Question 2 of 5
A patient was admitted to the mental health unit after arguing with co-workers and threatening to kill them. He is diagnosed with paranoid schizophrenia. On the unit he is aloof and suspicious. He mentioned that two physicians he saw talking were plotting to kill him. On the basis of data gathered at this point, which two primary nursing diagnoses should the nurse consider?
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes and Risk for other-directed violence. 1. Disturbed thought processes: The patient's delusions (believing physicians are plotting to kill him) indicate disorganized thinking, a hallmark of paranoid schizophrenia. 2. Risk for other-directed violence: The patient's threatening behavior towards co-workers suggests a potential for violence towards others. Incorrect choices: B: Spiritual distress and Social isolation - Not directly related to the patient's current symptoms of paranoid delusions and threat of violence. C: Risk for loneliness and Knowledge deficit - The patient's issues are more severe than loneliness or knowledge deficit. D: Disturbed personal identity and Nonadherence - While these issues may be relevant in schizophrenia, they are not the primary concerns presented in this scenario.
Question 3 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 (NMS). The patient's symptoms align with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, and elevated temperature, pulse, and blood pressure are all indicative of NMS. The nurse should suspect NMS and take immediate action by placing the patient in a cooling blanket to lower the temperature and transfer him to the ICU for close monitoring and further management. Choice B is incorrect because anticholinergic toxicity typically presents with different symptoms such as dry mouth, dilated pupils, and confusion. Choice C is incorrect as there are no signs of a psychotic relapse, and administering more antipsychotic medication could worsen the NMS. Choice D is incorrect as agranulocytosis presents with symptoms like fever and sore throat, not the combination of symptoms seen in this case.
Question 4 of 5
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The family cares for her during the evening and at night. Noting the patient had several bruises, the nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage because she is confused and wanders all night. She says the bruises resulted from a fall down stairs. The daughter states, "I have lost my mother, and I cannot bear it anymore. It is wrecking my family." The nursing intervention that should take priority is:
Correct Answer: B
Rationale: The correct answer is B: Identifying two options for caregiver respite and care assistance at night. This is the priority intervention because it addresses the immediate need to ensure the patient's safety and well-being while also supporting the daughter who is struggling to cope. By identifying options for caregiver respite and care assistance at night, the daughter can get the help she needs to manage her mother's care effectively without feeling overwhelmed. This intervention promotes both the patient's safety and the daughter's mental well-being. Choices A, C, and D are incorrect: A: Teaching the daughter more about the effects of Alzheimer's disease. While education is important, in this scenario, the immediate need is to address caregiver respite and care assistance. C: Supporting the daughter to grieve the loss of her mother's ability to function. While supporting the daughter emotionally is important, ensuring the patient's safety should take priority. D: Teaching the family how to give physical care more effectively and efficiently. While this is important
Question 5 of 5
An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
Correct Answer: B
Rationale: The correct answer is B: Consent signed by the patient. This is crucial as it ensures the patient's autonomy and willingness to undergo evidence collection. Without proper consent, the procedure would be unethical and potentially illegal. Vital signs (A) may be important for overall assessment but are not directly related to evidence collection. Supervision and credentials of the examiner (C) are necessary but not the most important documentation. The storage location of personal effects (D) is relevant for patient safety but not essential for evidence collection.