ATI RN
Concepts of Family Health Care Questions
Question 1 of 5
In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
Correct Answer: A
Rationale: The correct answer is A because stabilizing the patient's vital signs is the top priority in this critical situation. A blood pressure of 66/40 mm Hg indicates severe hypotension, which can lead to organ failure. A pulse of 140 bpm and shallow respirations of 8 bpm indicate poor perfusion and respiratory distress. Achieving a BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 bpm indicates improved perfusion and oxygenation, which are crucial for the patient's survival. Option B is incorrect as achieving a drug-free state is not the immediate priority in an overdose situation. Option C is incorrect as attending Narcotics Anonymous meetings is important for long-term recovery but not the immediate priority. Option D is incorrect as identifying community resources for substance abuse treatment is important but not as critical as stabilizing the vital signs in an overdose situation.
Question 2 of 5
An adult in the emergency department states, 'I feel restless. Everything I look at wavers. Sometimes I’m outside my body looking at myself. I hear colors. I think I’m losing my mind.' Vital signs are slightly elevated. The nurse should suspect a(n):
Correct Answer: D
Rationale: The correct answer is D, D-lysergic acid diethylamide (LSD) ingestion. LSD causes visual disturbances, dissociation, heightened sensory perceptions, and altered sense of reality, matching the client's symptoms. Vital signs being slightly elevated are consistent with LSD use. Schizophrenic episodes (A) involve long-term symptoms, not acute onset. Cocaine overdose (B) would present with more severe vital sign changes. PCP intoxication (C) typically causes aggression and hallucinations, not the described symptoms.
Question 3 of 5
Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse?
Correct Answer: B
Rationale: The correct answer is B, "When did you have your last drink?" This question is crucial in assessing the patient's current alcohol intake and potential withdrawal symptoms. Knowing this information helps determine the urgency of medical intervention and monitoring. Choice A focuses on past experiences, not immediate concerns. Choice C is important but does not address the patient's current condition. Choice D is relevant for treatment planning but not as urgent as knowing the last drink time for immediate assessment.
Question 4 of 5
While caring for a patient with a methamphetamine overdose, which tasks are the priority focuses of care? Select all that apply.
Correct Answer: D
Rationale: The correct answer is D: Prevention of seizures. Methamphetamine overdose can lead to seizures due to its effects on the central nervous system. Preventing seizures is crucial to avoid further complications. A: Administration of naloxone is used for opioid overdoses, not methamphetamine. B: Vitamin B12 and folate supplements may be beneficial for long-term recovery but are not the priority in the acute care of a methamphetamine overdose. C: Restoring nutritional integrity is important but not the immediate priority when managing a methamphetamine overdose. In summary, preventing seizures should be the priority focus of care for a patient with a methamphetamine overdose as it directly addresses a life-threatening complication of the overdose.
Question 5 of 5
The primary factor that makes an event a crisis is the:
Correct Answer: C
Rationale: The correct answer is C because the primary factor that makes an event a crisis is the ineffectiveness of one's usual coping strategies. When an event overwhelms an individual's ability to cope with it using their usual strategies, it can lead to a crisis. Choice A is incorrect because the type of loss alone does not determine if an event is a crisis. Choice B is incorrect as the nature of stress is subjective and can vary among individuals. Choice D is incorrect because the preexistence of a stress-related mental illness is not necessarily a prerequisite for an event to be considered a crisis.