ATI RN
Concept of Family Centered Care Questions
Question 1 of 5
Marie, age 56, is the mother of five children. Her youngest child, who had been living at home and attending the local college, recently graduated and accepted a job in another state. Marie has never worked outside the home and has devoted her life to satisfying the needs of her husband and children. Since the departure of her last child from home, Marie has become more and more despondent. Her husband has become very concerned, and takes her to the local mental health center. This type of crisis is called:
Correct Answer: B
Rationale: The correct answer is B: Crisis of anticipated life transitions. This type of crisis occurs when an individual faces major life changes that result in feelings of distress or uncertainty. In this scenario, Marie is experiencing a crisis due to the anticipated life transition of her youngest child leaving home. This event has disrupted her usual roles and routines, leading to feelings of despondency. Choice A (Dispositional crisis) refers to crises that arise from an individual's internal characteristics or coping mechanisms, which is not the case here. Choice C (Psychiatric emergency) is not applicable as there is no indication of severe or acute mental health issues requiring immediate intervention. Choice D (Crisis resulting from traumatic stress) does not fit the situation as there is no mention of a traumatic event triggering Marie's distress. In summary, the most appropriate term to describe Marie's crisis is a Crisis of anticipated life transitions, as it aligns with her current situation of struggling to adjust to the new phase of life after
Question 2 of 5
A patient who has AIDS expresses concern about telling others about the illness. Which response would be appropriate by the nurse?
Correct Answer: B
Rationale: The correct answer is B: "You should tell those who have a reason to know." This response is appropriate as it respects the patient's autonomy and privacy. By sharing the diagnosis with only those who need to know, the patient can control who has access to this sensitive information. This approach also promotes trust and open communication within the patient's support network. Option A is incorrect as it disregards the patient's right to privacy and may cause unnecessary stress. Option C is incorrect as it assumes the diagnosis will inevitably become public, which may not be the case if the patient chooses to keep it private. Option D is incorrect as it oversimplifies the situation and may not consider the patient's unique circumstances and preferences.
Question 3 of 5
The nurse is reviewing laboratory results for a patient who has HIV. Which result would be strongly suggestive of a diagnosis of AIDS?
Correct Answer: A
Rationale: The correct answer is A because a CD4+ count of 180/μL is significantly below the normal range (500-1500/μL) and indicative of severe immunosuppression, which is a hallmark of AIDS. CD4+ percentage alone (choice B) may not provide the full picture. CD8+ count (choice C) doesn't directly indicate immune system status in HIV/AIDS. The CD4+/CD8+ ratio (choice D) may be altered in various conditions, not specific to AIDS.
Question 4 of 5
A patient with AIDS-related wasting syndrome is very weak, lies listlessly in bed, has an intravenous (IV) drip, and receives antiretroviral medications via injection. What should be the priority nursing diagnosis for this patient?
Correct Answer: D
Rationale: The correct answer is D: Risk for Infection due to weak immune system and parenteral therapy. This is the priority nursing diagnosis because a patient with AIDS-related wasting syndrome is at high risk for infections due to their weak immune system and parenteral therapy, which can introduce pathogens into the body. Addressing the risk for infection is crucial in preventing further complications and promoting the patient's overall well-being. Choice A (Pain related to immobility) is not the priority as the patient's immobility is not the immediate concern compared to the risk of infection. Choice B (Ineffective Individual Coping due to terminal stage of HIV) may be a valid concern, but ensuring the patient's physical health and preventing infections take precedence. Choice C (Risk for Injury due to impaired mobility, weakness, and weight loss) is important but does not address the immediate threat of infection that the patient faces.
Question 5 of 5
The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient?
Correct Answer: D
Rationale: The correct answer is D (5 mm) for a positive Mantoux test in a patient with HIV. In HIV-positive individuals, a positive test is considered when the induration is ≥5 mm. This is because the immune system may be compromised, leading to a delayed immune response. Choices A, B, and C (2 mm, 3 mm, 4 mm) are not considered positive for HIV-positive individuals due to their weakened immune system, requiring a larger induration size to indicate a positive test.