ATI RN
Age Specific Care Questions
Question 1 of 5
Several children a day are seen in the emergency department for treatment of illnesses and injuries. The situation that would create a high index of suspicion of child abuse is a child who:
Correct Answer: C
Rationale: The correct answer is C because perineal bruises and urinary tract infections are physical signs that are highly suspicious for child abuse, particularly sexual abuse. Perineal bruises are not commonly seen in children due to accidental injuries, and urinary tract infections in young children are rare and may indicate sexual abuse. Repeated middle ear infections (choice A) and complaints of abdominal cramps and upset stomach (choice B) are common childhood illnesses that do not necessarily indicate child abuse. Displaying reduced functioning at school (choice D) may suggest various issues such as learning disabilities or emotional distress, but is not specific to child abuse.
Question 2 of 5
A child, age 9, is being evaluated in the Emergency Department at the hospital. Her mother reports that the child fell down the stairs in her home. Her mother is with her and describes her as a 'clumsy kid.' The nurse practitioner suspects child abuse. Which of these findings indicates that physical abuse may be a chronic problem for the child?
Correct Answer: B
Rationale: The correct answer is B - Unhealed fractures revealed on x-ray. This finding indicates chronic physical abuse as unhealed fractures suggest repeated trauma over time. This is concerning because chronic abuse can lead to severe physical and emotional consequences for the child. A: Bloody nose and blackened eyes may indicate acute physical abuse, but not necessarily chronic abuse. C: Clinging to her mother as she attempted to leave is a behavior often seen in children who are anxious or scared in a medical setting, but it does not specifically indicate chronic physical abuse. D: Struggling with the staff that attempts to obtain a blood specimen could be a response to fear or discomfort with medical procedures, which does not definitively point to chronic abuse.
Question 3 of 5
A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to my husband, since he continues to abuse me.' The nurse is aware that the final decision to leave a batterer:
Correct Answer: B
Rationale: The correct answer is B: Is usually a gradual process that occurs over time. Rationale: 1. Leaving an abusive partner is a complex and difficult decision that often requires careful planning and support. 2. Victims may face various barriers such as financial dependence, emotional attachment, and fear of further violence. 3. It is rare for victims to abruptly leave without considering their safety and well-being. 4. The statement 'I probably should not keep going back' indicates a gradual realization and contemplation of leaving. Summary: A: The decision to leave is not solely based on serious injury; victims may leave before any significant harm occurs. C: Approval from the church may influence the victim's decision but is not a determining factor. D: Leaving an abusive partner should not require the batterer's permission; it is a personal choice made by the victim.
Question 4 of 5
A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacantly. You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
Correct Answer: C
Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication. Rationale: 1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances. 2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion. 3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself. Summary: A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem. B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario. D: Disturbed body image, anxiety, pain - Disturbed
Question 5 of 5
A client has been diagnosed with Alzheimer's disease, stage 1. The nurse would expect to help the family plan measures to assist the client with:
Correct Answer: A
Rationale: The correct answer is A: Recent memory loss. In stage 1 of Alzheimer's disease, the primary symptom is mild memory loss, particularly with recent events and information. The nurse would help the family plan measures to assist the client by implementing strategies to support memory, such as setting reminders, organizing daily routines, and using memory aids. Choice B, catastrophic reactions, is more commonly associated with later stages of the disease. Choice C, progressive gait disturbances, is not a typical symptom of stage 1 Alzheimer's. Choice D, perseveration, involves the repetition of a particular response or behavior and is not a primary concern in stage 1 Alzheimer's disease.