ATI RN
Age Specific Patient Care Questions
Question 1 of 5
The daughter of an 84-year-old client with dementia tearfully tells the nurse that she doesn't know what's wrong with her mother, who has begun accusing the family of stealing her lingerie and holding her prisoner. The nurse identifies which of the following nursing diagnosis for the client?
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This nursing diagnosis is appropriate because the client's symptoms suggest cognitive impairment and delusions, which are common in dementia. The client's accusations of theft and imprisonment indicate a distortion in reality perception, reflecting disturbed thought processes. Powerlessness (B) relates more to lack of control over circumstances, not cognitive issues. Ineffective coping (C) and Defensive coping (D) focus on emotional responses rather than cognitive impairment.
Question 2 of 5
For those family members who desire to care at home for loved ones who have been given a diagnosis of Alzheimer's disease, it is important for the nurse to ensure that the family is aware of which caregiver skills and responsibilities will be necessary. What is one of the responsibilities of the caregiver during the middle stage of the disease?
Correct Answer: D
Rationale: The correct answer is D: Adapting to the changing personality and behavior of the loved one. During the middle stage of Alzheimer's disease, individuals may experience significant changes in personality and behavior. Caregivers need to adapt to these changes by being patient, understanding, and flexible. This responsibility is crucial for maintaining a positive and supportive relationship with the loved one. A: Helping the loved one with memory and communication problems is important, but it is more relevant in the early stages of the disease when these issues are more prominent. B: Providing a stable, routine environment is essential throughout all stages of Alzheimer's disease, not just the middle stage. C: Providing complete assistance with physical care may become necessary in the later stages of the disease when the individual's physical abilities decline significantly.
Question 3 of 5
A 25-year-old individual was brought by ambulance to the emergency room. The patient's sensorium alternates between clouded and clear, and the patient becomes agitated both physically and verbally when approached. The patient's cognitive impairment is most consistent with:
Correct Answer: A
Rationale: The correct answer is A: Delirium. Delirium is characterized by acute onset, fluctuating course, altered level of consciousness, and cognitive impairment. In this case, the patient's alternating sensorium and agitation suggest an acute confusional state, which is typical of delirium. Delirium is often caused by underlying medical conditions, medications, or substance abuse. Summary of other choices: B: Dementia is a chronic, progressive cognitive decline that does not typically present with acute onset and fluctuating symptoms like delirium. C: Sundown syndrome refers to worsening of symptoms in the evening and is often seen in patients with dementia, not in this acute and fluctuating presentation. D: Early-onset Alzheimer's disease is a form of dementia that typically has a more insidious onset and does not present with acute fluctuations in cognition like delirium.
Question 4 of 5
The nurse is assisting a victim of spousal abuse to create a plan for escape if it becomes necessary. What components should the plan include? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: A code word to signal children that it is time to leave. This is crucial for ensuring the safety of the victim and their children without alerting the abuser. Other choices like B, providing phone numbers for shelters, are important but may not always be feasible in an emergency. Choice C, informing the spouse about the plan, can escalate the situation. Choice D, collecting essential documents, is important but may not always be the immediate priority in a dangerous situation. Having a code word ensures a discreet and quick escape if needed.
Question 5 of 5
The nurse is interviewing a client who presents with a dislocated shoulder. She demonstrates signs of anxiety and poor eye contact and turns to her partner for answers, allowing him to speak for her. The nurse asks the partner to go to the admitting office to give insurance information. While the partner is out of the room, which question is most important to ask?
Correct Answer: A
Rationale: Step 1: By asking how the shoulder dislocation occurred, the nurse can assess the mechanism of injury and potential risk factors for further harm. Step 2: Understanding the cause can guide treatment decisions and prevent future injuries. Step 3: This question is crucial for providing appropriate care and ensuring the client's safety. Summary: Option A is the correct answer as it directly relates to the client's current condition and allows the nurse to gather essential information for effective care. Options B and C are not as pertinent at this moment, and option D is incorrect as gathering information from the client is essential in this situation.