ATI RN
Age Specific Care Questions
Question 1 of 5
Police bring a patient to the mental health unit. The patient was directing traffic and shouting rhymes on a busy city street. The patient's spouse reports that the patient has not slept or eaten for 3 days. Which assessment findings have priority concern for this patient's plan of care?
Correct Answer: B
Rationale: The correct answer is B. Hyperactivity, not eating, and not sleeping are priority concerns as they indicate potential mania or hypomania, which can be dangerous and require immediate intervention. Not eating and sleeping for days can lead to physical and mental health complications. Pressured speech and grandiosity (Choice A) are symptoms of mania but not as urgent as lack of eating and sleeping. Poor concentration and decision making (Choice C) are also symptoms of mania, but not as immediately concerning as the lack of eating and sleeping. Insulting behavior (Choice D) is not a priority concern for immediate intervention in this scenario.
Question 2 of 5
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
Correct Answer: C
Rationale: The correct answer is C: Disturbed thought processes. The client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disturbance in thought processes. This nursing diagnosis focuses on the client's cognitive functioning and perception of reality. A: Risk for violence is not the most appropriate diagnosis in this case as there is no direct evidence of the client being a risk to herself or others. B: Defensive coping does not address the client's specific symptoms of delusions and disorganized thinking. D: Impaired memory is not the most appropriate diagnosis as the client's symptoms are more indicative of a broader disturbance in thought processes rather than just memory deficits. Therefore, choice C is the most suitable nursing diagnosis based on the client's presentation of delusional behavior and disorganized thoughts.
Question 3 of 5
The mother of a client newly diagnosed with schizophrenia is a nurse. She unhappily tells the nurse on the unit, 'I've tried to be a good mother, but my daughter still developed schizophrenia. When I was in school, we were taught that it was the mother's fault if a child became schizophrenic. I wish I knew what I did wrong.' The response that would help the mother evaluate models explaining schizophrenia would be:
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Choice B is the correct answer because it provides the mother with new information that schizophrenia is biologic in nature, shifting the blame away from her. 2. This response helps the mother understand that her daughter's condition is not her fault, based on current scientific understanding. 3. By offering this information, the nurse helps the mother reevaluate her beliefs and perceptions about the causes of schizophrenia. 4. Choices A, C, and D do not address the mother's concerns directly or provide her with the necessary information to understand the biological basis of schizophrenia.
Question 4 of 5
An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. At this point, the risperidone medication would have had sufficient time to begin exerting its therapeutic effects on the individual's symptoms of hallucinations and delusions. It typically takes a few days for antipsychotic medications like risperidone to reach therapeutic levels in the body and start alleviating psychotic symptoms. By day 3, the individual may start to demonstrate improved trust in the nurse due to the reduction in distressing symptoms. Incorrect options: A: Day of admission - It is unlikely to see significant improvement in symptoms and trust on the same day of admission. C: Day 5 of hospitalization - By this time, the medication would have likely already started showing some effects, and the individual would have had some time to build trust with the nurse. D: Day 7 of hospitalization - Waiting until day 7 might be too late to note beginning trust and significant reduction in symptoms, as the
Question 5 of 5
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
Correct Answer: D
Rationale: The correct answer, D, is indicative of auditory hallucinations. Darting eyes may suggest that the patient is hearing voices, distracted behavior aligns with responding to internal stimuli, and mumbling to oneself could be a response to hearing voices. Choices A, B, and C do not directly relate to auditory hallucinations, as they are more indicative of other mental health symptoms such as social withdrawal, mania, anxiety, or compulsive behaviors. Selecting D helps identify potential auditory hallucinations based on observed behaviors associated with hearing voices.