ATI RN
Age Specific Patient Care Questions
Question 1 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. This response acknowledges the mother's distress but shifts the focus to new findings suggesting schizophrenia is biologic in nature. 2. It provides the mother with updated information that contradicts the outdated belief that mothers are to blame for schizophrenia. 3. By highlighting the biological basis of the disorder, it helps the mother understand that it is not her fault. 4. This response encourages the mother to consider scientific evidence rather than blaming herself, promoting a more accurate understanding of the condition. Summary: - Choice A validates the mother's feelings but doesn't offer factual information to challenge her belief. - Choice C aims to provide emotional support but doesn't address the mother's need for accurate information. - Choice D introduces the concept of double-bind communication, which is not directly relevant to helping the mother understand the biological nature of schizophrenia.
Question 2 of 5
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect ______ and should ______.
Correct Answer: A
Rationale: The correct answer is A: neuroleptic malignant syndrome (NMS). The patient's symptoms align with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, and elevated temperature, pulse, and blood pressure are all indicative of NMS. The nurse should suspect NMS and take immediate action by placing the patient in a cooling blanket to lower the temperature and transfer him to the ICU for close monitoring and further management. Choice B is incorrect because anticholinergic toxicity typically presents with different symptoms such as dry mouth, dilated pupils, and confusion. Choice C is incorrect as there are no signs of a psychotic relapse, and administering more antipsychotic medication could worsen the NMS. Choice D is incorrect as agranulocytosis presents with symptoms like fever and sore throat, not the combination of symptoms seen in this case.
Question 3 of 5
A patient, aged 82 years, has Alzheimer's disease. She lives with her daughter's family and goes to a day care facility on weekdays. The family cares for her during the evening and at night. Noting the patient had several bruises, the nurse discussed her observations with the daughter, who became defensive and said that her mother was very difficult to manage because she is confused and wanders all night. She says the bruises resulted from a fall down stairs. The daughter states, "I have lost my mother, and I cannot bear it anymore. It is wrecking my family." The nursing intervention that should take priority is:
Correct Answer: B
Rationale: The correct answer is B: Identifying two options for caregiver respite and care assistance at night. This is the priority intervention because it addresses the immediate need to ensure the patient's safety and well-being while also supporting the daughter who is struggling to cope. By identifying options for caregiver respite and care assistance at night, the daughter can get the help she needs to manage her mother's care effectively without feeling overwhelmed. This intervention promotes both the patient's safety and the daughter's mental well-being. Choices A, C, and D are incorrect: A: Teaching the daughter more about the effects of Alzheimer's disease. While education is important, in this scenario, the immediate need is to address caregiver respite and care assistance. C: Supporting the daughter to grieve the loss of her mother's ability to function. While supporting the daughter emotionally is important, ensuring the patient's safety should take priority. D: Teaching the family how to give physical care more effectively and efficiently. While this is important
Question 4 of 5
An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?
Correct Answer: B
Rationale: The correct answer is B: Consent signed by the patient. This is crucial as it ensures the patient's autonomy and willingness to undergo evidence collection. Without proper consent, the procedure would be unethical and potentially illegal. Vital signs (A) may be important for overall assessment but are not directly related to evidence collection. Supervision and credentials of the examiner (C) are necessary but not the most important documentation. The storage location of personal effects (D) is relevant for patient safety but not essential for evidence collection.
Question 5 of 5
A person who was raped comes to the hospital for treatment. The person abruptly decides to decline treatment and leave the facility. Before this person leaves, the nurse should:
Correct Answer: B
Rationale: The correct answer is B because providing written information about physical and emotional reactions respects the individual's autonomy and empowers them to make informed decisions. It also ensures they have resources to understand and cope with potential consequences. Choice A violates the individual's right to refuse treatment. Choice C focuses on specific tests without addressing the person's immediate concerns. Choice D, while important, is not as immediate or relevant as providing information on potential reactions.