ATI RN
Assessing Health Behavior Nursing Questions
Question 1 of 5
The desired outcome for a patient experiencing insomnia is, 'Patient will sleep for a minimum of 5 hours nightly within 7 days.' At the end of 7 days, review of sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action?
Correct Answer: D
Rationale: The correct response to this question involves applying the evaluation step of nursing process. Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the period for attaining the outcome may be appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. Removing this nursing diagnosis from the plan of care would be correct when the outcome was met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.
Question 2 of 5
A nurse is caring for a patient diagnosed with anorexia nervosa. The patient states, 'I don't care about food. I'm afraid to eat.' Which of the following is the most appropriate response by the nurse?
Correct Answer: B
Rationale: The most appropriate response by the nurse is option B: "Let's talk about why you're afraid to eat and how we can help you." This response demonstrates therapeutic communication by acknowledging the patient's feelings and offering support to address the underlying issues causing the fear of eating in a patient with anorexia nervosa. Option A is incorrect because it is dismissive of the patient's feelings and lacks empathy, which can further alienate the patient and hinder the therapeutic relationship. Telling the patient they "need to eat" without addressing the underlying fear does not promote trust or collaboration in care. Option C is incorrect as it focuses solely on the physical aspect of eating to regain strength, neglecting the psychological and emotional factors contributing to the patient's fear of food. Recovery from anorexia nervosa requires a holistic approach that considers both physical and mental health aspects. Option D is also incorrect because it disregards the patient's autonomy and places undue pressure by demanding blind trust. Building trust in the therapeutic relationship involves understanding the patient's concerns and working collaboratively towards recovery. In an educational context, this question highlights the importance of empathetic and patient-centered communication in nursing care, especially when dealing with complex mental health issues like eating disorders. Nurses must approach patients with empathy, respect, and a willingness to address the underlying emotional issues to provide effective care and support in the recovery process.
Question 3 of 5
A nurse documents: 'Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker.' Which nursing diagnosis should be considered?
Correct Answer: D
Rationale: The correct answer is D) Impaired verbal communication. This nursing diagnosis is appropriate based on the assessment findings provided in the question. The patient's inability to speak, lack of eye contact, and disinterest in interaction indicate a deficit in verbal communication skills. This diagnosis highlights the patient's difficulty in expressing thoughts, needs, and feelings verbally, which can significantly impact their ability to communicate effectively with healthcare providers and receive appropriate care. Option A) Defensive coping is incorrect because the patient's behavior is not indicative of using defense mechanisms to manage stress or conflict. The behaviors described do not suggest a conscious effort to cope with a challenging situation. Option B) Decisional conflict is incorrect as there is no evidence in the scenario to support the idea that the patient is experiencing uncertainty or indecisiveness regarding a choice to be made. The patient's lack of verbal communication does not necessarily imply decisional conflict. Option C) Risk for other-directed violence is also incorrect as there is no indication of potential harm or violence towards others in the patient's behavior. The behaviors described in the question are more indicative of communication challenges rather than aggressive tendencies. In an educational context, understanding how to analyze assessment data to formulate appropriate nursing diagnoses is crucial for effective patient care. Nurses must be able to interpret patient behaviors and cues to identify underlying issues and provide targeted interventions. In this case, recognizing impaired verbal communication allows nurses to implement strategies to support the patient in overcoming communication barriers and promoting holistic care.
Question 4 of 5
A nurse says, 'I am the only one who truly understands this patient. Other staff members are too critical.' The nurse's statement indicates
Correct Answer: A
Rationale: When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming overinvolved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.
Question 5 of 5
The patient says, 'My marriage is just great. My spouse and I always agree.' The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patient's communication is
Correct Answer: B
Rationale: The patient's verbal and nonverbal communication in this scenario are incongruous. Incongruous messages involve transmission of conflicting messages by the speaker. The patient's verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.