ATI RN
Population Specific Care Questions
Question 1 of 5
An advance directive gives legally binding direction for health care interventions when a patient
Correct Answer: C
Rationale: The correct answer is C because an advance directive is a legal document that specifies a person's wishes for healthcare decisions if they are unable to make decisions for themselves due to illness. This ensures their preferences are followed. Choices A and B are specific diagnoses and do not address decision-making capacity. Choice D focuses on the inability to speak, which is just one aspect of decision-making ability, but not comprehensive enough for an advance directive.
Question 2 of 5
Which finding for a patient with an eating disorder most clearly indicates the need for hospitalization?
Correct Answer: B
Rationale: The correct answer is B because urine output less than 30 mL/hr indicates severe dehydration and compromised kidney function, which can lead to organ failure. Hospitalization is necessary for immediate fluid resuscitation and monitoring. Option A is indicative of malnutrition but does not directly signify acute medical complications. Option C suggests hypokalemia, which can be managed on an outpatient basis. Option D, a low pulse rate, may be a sign of bradycardia but typically does not require immediate hospitalization unless accompanied by other severe symptoms.
Question 3 of 5
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
Question 4 of 5
The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?
Correct Answer: B
Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline. Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms. Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome. Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome. Summary: - Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome. - Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention. - Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.
Question 5 of 5
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _____, and the nurse should _____.
Correct Answer: A
Rationale: The correct answer is A: A dystonic reaction"¦administer PRN IM benztropine (Cogentin). This patient is exhibiting symptoms of acute dystonia, a extrapyramidal side effect of haloperidol. Dystonic reactions are characterized by sustained muscle contractions causing abnormal postures. Benztropine is an anticholinergic medication that helps alleviate these symptoms by blocking the neurotransmitter acetylcholine. Administering benztropine is the appropriate treatment for acute dystonia. Summary of other choices: B: Tardive dyskinesia"¦seek a change in the drug or its dosage - Tardive dyskinesia is a side effect that occurs after long-term antipsychotic use, not acutely like in this case. C: Waxy flexibility"¦continue treatment with antipsychotic drugs - Waxy flexibility is a symptom of catatonia, not a side effect of antipsychotic medications