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: Failed to generate a rationale of 500+ characters after 5 retries.
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: Failed to generate a rationale of 500+ characters after 5 retries.
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.