ATI RN
Target Healthcare Questions
Question 1 of 5
An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. Typically, antipsychotic medications like risperidone take a few days to start showing noticeable effects in reducing hallucinations and delusions. By day 3, the medication would have had enough time to begin its therapeutic effect. Building trust with a psychotic patient also takes time, so by day 3, the patient may start showing signs of trust in the nurse. Day of admission (Choice A) is too early for the medication to take effect. Day 5 (Choice C) and Day 7 (Choice D) are too late as the medication usually shows noticeable improvement within the first few days.
Question 2 of 5
A patient was admitted in a semistuporous catatonic state. Family states that the patient has neither left the apartment nor attended to personal hygiene for several weeks. The patient's last 48 hours have been spent lying in bed, mute and motionless. The nursing diagnosis that should be considered the priority is:
Correct Answer: A
Rationale: The correct answer is A: self-care deficit. The patient's symptoms indicate a lack of ability to perform self-care activities, which poses a risk to their health and well-being. This is a priority as addressing this issue will directly impact the patient's physical health and overall functioning. Situational low self-esteem (B) is not the priority as it focuses on the patient's emotional state rather than their immediate physical needs. Disturbed thought processes (C) and impaired verbal communication (D) may be present but are not the priority over the patient's inability to perform self-care activities.
Question 3 of 5
A patient, aged 77 years, has Alzheimer's disease and lives with her daughter. While checking her blood pressure at the clinic, the nurse noticed fresh bruises on the patient's palms and buttocks. The patient could not explain these bruises. The nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage. She stated, "My mother is getting worse every week. She is not my mother anymore. She can't recognize me, and she wanders all night. We take turns because she has to be watched constantly. Last night I fell asleep, and she fell down the stairs while wandering." Which statement is most accurate?
Correct Answer: A
Rationale: Step 1: The nurse observed bruises on the patient's palms and buttocks. Step 2: The patient could not explain these bruises. Step 3: The daughter mentioned the patient's worsening condition and the incident of falling down the stairs. Step 4: The daughter's statement indicates the patient's deteriorating cognitive and physical abilities. Step 5: The daughter's challenges in managing the patient are due to the progression of Alzheimer's disease. Step 6: There is no explicit evidence or indication of elder abuse based on the provided information. Step 7: Reporting the injuries without clear signs of abuse may harm the patient's relationship with the daughter. Step 8: Therefore, the most appropriate action is not to report the injuries based on the available data to avoid potential harm. Summary: - Choice A is correct as reporting the injuries is not indicated by the available data. - Choices B, C, and D are incorrect as there is no clear evidence of elder abuse in the scenario
Question 4 of 5
A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me." The nurse should:
Correct Answer: B
Rationale: The correct answer is B: Explain that bathing would destroy evidence. This is the correct choice because bathing can potentially wash away crucial forensic evidence that can be collected during a sexual assault examination. Preserving evidence is essential for legal proceedings and ensuring justice for the victim. Choice A is incorrect because arranging for the patient to shower would destroy evidence. Choice C is incorrect as giving the patient a basin of water and towels would still risk destroying evidence. Choice D is also incorrect as it does not address the importance of preserving evidence in cases of sexual assault.
Question 5 of 5
A new client admits to having been battered by her live-in boyfriend several times over the past 2 years. She states to the nurse, 'We plan to get married next June, and I think things will be better then. He is always so sorry afterward, that I think I can trust him to change.' Which intervention should be included in the client's teaching plan?
Correct Answer: D
Rationale: The correct answer is D: Assist her in developing an emergency plan, since the pattern of violence is likely to continue. This choice is correct because it focuses on safety planning, which is crucial for individuals in abusive relationships. By helping the client develop an emergency plan, the nurse is acknowledging the seriousness of the situation and providing practical strategies to ensure her safety. It is important to have a plan in place in case of future violence. Explanation for the incorrect choices: A: Supporting her hope that the battering will end after they are married is not appropriate as it may give false hope and does not address the immediate safety concerns. B: Enrolling in a self-defense class may not be effective in situations of domestic violence as it can escalate the violence and may not address the underlying issues causing the abuse. C: Emphasizing that the battering pattern usually remains the same in frequency and severity over time is not as helpful as developing a concrete safety plan to address the immediate danger.