ATI RN
Age Specific Care Questions
Question 1 of 5
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy." A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
Question 2 of 5
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is 2.7 mg/dL. Which nursing diagnosis applies?
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia. Rationale: 1. Anorexia nervosa involves severe restriction of food intake, leading to significant weight loss and malnutrition. 2. The patient's history of virtually stopping eating and losing 25% of body weight aligns with the nursing diagnosis of imbalanced nutrition. 3. Hypokalemia (low serum potassium level) is common in patients with anorexia nervosa due to inadequate intake or purging behaviors. 4. The other choices are incorrect because they do not match the patient's specific presentation of anorexia nervosa and hypokalemia.
Question 3 of 5
A nursing intervention that will be planned to occur early in the nurse-patient relationship with a client with an eating disorder is:
Correct Answer: A
Rationale: The correct answer is A: formulating a nurse-client contract. This intervention is essential early in the nurse-patient relationship with a client with an eating disorder because it establishes clear boundaries, roles, and expectations. By creating a contract, both the nurse and the client can communicate openly about their goals, responsibilities, and treatment plan. This helps build trust, promotes collaboration, and provides a framework for the therapeutic relationship. Choices B, C, and D are incorrect: B: Using confrontation to attack denial may be counterproductive and harmful in the early stages of the relationship as it can lead to resistance and damage trust. C: Placing the client in a therapeutic group may be beneficial at a later stage but not necessarily an appropriate early intervention when individual needs should be addressed first. D: Attacking enmeshment by separating client and family is not a suitable early intervention as it may cause distress and disrupt important support systems.
Question 4 of 5
A client with an eating disorder that has resulted in weight loss to a point 15% below normal weight tells the nurse, 'I don't need to be hospitalized. I can control myself.' The nurse continues to prepare the client for hospitalization because the vicious cycle of eating disorder behavior is fueled by:
Correct Answer: A
Rationale: The correct answer is A: feelings of power and control resulting from weight loss. In clients with eating disorders, the behavior is often driven by a sense of control and power gained through weight loss. This reinforces the cycle of the disorder as the individual feels empowered by their ability to restrict food intake. This false sense of control becomes a driving force in the continuation of the disorder. Incorrect answers: B: Dysfunctional family dynamics may contribute to the development of an eating disorder, but in this scenario, the client's refusal for hospitalization is more related to their own sense of control rather than family dynamics. C: Faulty use of the defense mechanism projection is not the primary reason for the client's resistance to hospitalization in this case. D: Lack of superego constraints on behavior is not the main factor driving the client's refusal for hospitalization.
Question 5 of 5
Children should undergo further evaluation when their weight is % above their height.
Correct Answer: C
Rationale: The correct answer is C (20%). This is because a weight that is 20% above a child's height can indicate potential health issues such as obesity. Excess weight can lead to various health problems in children. Choices A, B, and D are incorrect as they represent lower percentages, which may not be as concerning in terms of potential health risks. It is important to consider a higher percentage threshold for further evaluation to ensure early detection and intervention for any weight-related issues.