ATI RN
Age Specific 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. Choice B is the correct answer because it provides the mother with new information that schizophrenia is biologic in nature, shifting the blame away from her. 2. This response helps the mother understand that her daughter's condition is not her fault, based on current scientific understanding. 3. By offering this information, the nurse helps the mother reevaluate her beliefs and perceptions about the causes of schizophrenia. 4. Choices A, C, and D do not address the mother's concerns directly or provide her with the necessary information to understand the biological basis of schizophrenia.
Question 2 of 5
A patient's nursing care plan includes assessment for auditory hallucinations. Indicators that suggest the patient may be hallucinating include:
Correct Answer: D
Rationale: The correct answer, D, is indicative of auditory hallucinations. Darting eyes may suggest that the patient is hearing voices, distracted behavior aligns with responding to internal stimuli, and mumbling to oneself could be a response to hearing voices. Choices A, B, and C do not directly relate to auditory hallucinations, as they are more indicative of other mental health symptoms such as social withdrawal, mania, anxiety, or compulsive behaviors. Selecting D helps identify potential auditory hallucinations based on observed behaviors associated with hearing voices.
Question 3 of 5
A patient with the diagnosis of schizophrenia, disorganized type, approaches the nurse and says, 'It's beat, it's eat. No room for doom.' The nurse can correctly assess this verbalization as:
Correct Answer: B
Rationale: The correct answer is B: clanging. Clanging refers to the pattern of speech characterized by the association of words based on sound rather than meaning. In this case, the patient's verbalization, "It's beat, it's eat. No room for doom," demonstrates a connection based on rhyming sounds rather than coherent meaning. This is a classic example of clanging commonly seen in individuals with disorganized schizophrenia. Neologisms (choice A) refer to new words created by the individual, ideas of reference (choice C) involve believing that external events have special significance for oneself, and associative looseness (choice D) pertains to a lack of logical connection between thoughts. These choices are incorrect as they do not accurately describe the patient's speech pattern in this scenario.
Question 4 of 5
The physician and advanced practice nurse are considering which antipsychotic medication to prescribe for a patient with schizophrenia who demonstrates auditory hallucinations, apathy, anhedonia, and poor social functioning. The patient is overweight and has hypertension. Bearing these facts in mind, the drug the nurse should advocate would be:
Correct Answer: D
Rationale: The correct answer is D: aripiprazole (Abilify). Aripiprazole is a second-generation antipsychotic that is less likely to cause weight gain and metabolic side effects compared to other antipsychotics. This is important since the patient is already overweight and has hypertension. Aripiprazole also has a lower risk of causing sedation, which can be beneficial for addressing apathy and anhedonia without worsening social functioning. A: Clozapine is effective for treatment-resistant schizophrenia but is associated with significant weight gain and metabolic side effects. B: Haloperidol is a first-generation antipsychotic with a high risk of extrapyramidal side effects and is not ideal for a patient with hypertension. C: Olanzapine is known for causing significant weight gain and metabolic effects, making it a less suitable choice for an overweight patient with hypertension.
Question 5 of 5
The nursing diagnosis most likely to be used for a person who has a diagnosis of schizophrenia, paranoid type, is:
Correct Answer: A
Rationale: Step-by-step rationale for choice A: 1. Schizophrenia, paranoid type, involves mistrust and suspicion. 2. Impaired ability to trust can lead to social isolation. 3. "Impaired ability to trust" directly relates to social isolation. 4. Therefore, "social isolation related to impaired ability to trust" is the most likely nursing diagnosis. Summary of other choices: - B: Not directly related to mistrust in paranoid schizophrenia. - C: Lack of confidence in significant others is not a defining characteristic of paranoid schizophrenia. - D: Impaired memory is not a primary feature of paranoid schizophrenia.