ATI RN
Age Specific Considerations in Patient Care Questions
Question 1 of 5
In planning aftercare for a client with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the client to have stimulation, structure, socialization, and support. Which option would best incorporate these factors?
Correct Answer: B
Rationale: The correct answer is B: Attending a psychosocial club. This option best incorporates the necessary factors of stimulation, structure, socialization, and support for the client with schizophrenia. - Stimulation: Psychosocial clubs offer various activities to engage the client's mind and keep them occupied. - Structure: These clubs usually have regular schedules and routines, providing the client with a sense of order and predictability. - Socialization: Interacting with others in the club can help the client improve social skills and combat feelings of isolation. - Support: Being part of a community in the club can provide emotional support and encouragement for the client. Incorrect Choices: - A: Day hospitalization may offer structure and support but may lack the socialization and stimulation provided by a psychosocial club. - C: Living with his elderly mother may provide support but may not offer the necessary stimulation, structure, and socialization outside of the home environment. - D: Spending free time in the mall may offer
Question 2 of 5
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
Correct Answer: B
Rationale: The correct answer is B: tardive dyskinesia"¦administer the Abnormal Involuntary Movement Scale. 1. Tardive dyskinesia is a side effect of long-term use of antipsychotic medications like fluphenazine. 2. The symptoms described - grimacing, lip smacking, twisting neck and shoulders - are characteristic of tardive dyskinesia. 3. Administering the Abnormal Involuntary Movement Scale is the appropriate assessment tool for diagnosing tardive dyskinesia. 4. Agranulocytosis (choice A) is a rare but serious side effect of some antipsychotic medications, not associated with the symptoms described. 5. Tourette's syndrome (choice C) typically presents with vocal and motor tics, not the specific symptoms mentioned. 6. Anticholinergic effects (choice D) can cause dry mouth, constipation, and blurred vision, but not the involuntary movements described.
Question 3 of 5
A patient with schizophrenia who admits to auditory hallucinations anxiously tells the nurse, 'The voice is telling me to do things.' Which of the following responses should the nurse make next?
Correct Answer: D
Rationale: The correct answer is D: "What is the voice telling you to do?" This response helps the nurse assess the content and potential danger of the hallucinations, guiding further interventions. Option A focuses on recognition, which is less urgent. Option B addresses duration, not immediate safety. Option C inquires about fear but does not directly address the hallucination's content. By asking what the voice commands, the nurse gains crucial insight for risk assessment and safety planning.
Question 4 of 5
A severely withdrawn patient diagnosed with schizophrenia will spend time in the dayroom but will not speak to staff or to other patients. The most therapeutic nursing intervention in response to this behavior would be to:
Correct Answer: D
Rationale: The correct answer is D because it focuses on building a therapeutic relationship with the patient without placing pressure on them to speak. By planning time for staff members to sit with the patient, even if the patient does not talk, it allows for nonverbal communication and presence to convey support and care. This approach respects the patient's boundaries and allows them to engage at their own pace, fostering trust and a sense of safety. Choice A is incorrect as it may overwhelm the patient by placing them in a social situation they are not ready for. Choice B is incorrect as discussing superficial topics does not address the patient's underlying issues. Choice C is incorrect as it may make the patient feel judged or pressured to speak, further isolating them.
Question 5 of 5
A patient reports, 'My brain is tapped by government agents who can trace my whereabouts and listen to my thoughts.' An appropriate nursing response to this information would be:
Correct Answer: C
Rationale: The correct response is C because it focuses on exploring the underlying reasons for the patient's belief, which can help uncover any triggers or stressors leading to the delusion. This approach shows empathy, builds rapport, and encourages the patient to share more about their experiences. Choice A is dismissive and may cause the patient to feel invalidated. Choice B only focuses on the belief itself without delving deeper into the context. Choice D jumps to assumptions about the patient's emotions without addressing the core issue of the delusion. Overall, choice C promotes therapeutic communication and understanding of the patient's perspective.