ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Asking the patient if they trust the nurse to help with the voices is the least impactful at this point because establishing trust should have already been a priority earlier in the hospitalization. The focus now should be on assessing the nature and frequency of the auditory hallucinations to guide further treatment and intervention. Summary of Incorrect Choices: B: This question is important to assess if the voices are commanding potentially harmful actions. C: Understanding the frequency of the voices is crucial in evaluating the severity of the symptoms. D: Inquiring about hearing voices in different environments helps assess the impact of external factors on the hallucinations.
Question 2 of 5
A nurse works a rape telephone hotline. Communication should focus on:
Correct Answer: A
Rationale: The correct answer is A because in cases of sexual assault, immediate steps such as seeking medical attention, preserving evidence, and contacting authorities are crucial. Providing sympathy (B) is important but secondary to ensuring victims' safety. Obtaining information for law enforcement (C) should only be done if victims consent, as their safety and well-being are the priority. Long-term counseling (D) is important but not the immediate focus on a hotline call.
Question 3 of 5
Which nursing intervention will assist a client being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Providing a safe, nonintimidating environment is crucial to encourage the client to disclose domestic violence. This approach helps establish trust and confidentiality, making the client feel secure to share sensitive information. It creates a conducive setting for open communication without fear of repercussions. Summary of Incorrect Choices: A: Interviewing her in the presence of another professional may not ensure privacy and could potentially increase the client's discomfort or fear of being overheard. B: Speaking with the client in the absence of her husband might not guarantee safety and confidentiality, as the client may still feel threatened or hesitant to reveal the abuse. D: Allowing the client to initiate the topic of violence puts the burden on the client, who may already be feeling overwhelmed or unable to bring up the sensitive issue without support and encouragement.
Question 4 of 5
A nurse planning teaching for a parent group concerned with preventing family violence can discuss the fact that exposure to violence in the media:
Correct Answer: C
Rationale: The correct answer is C: Desensitizes people to the violence around them. Exposure to violence in the media can desensitize individuals, leading them to become less sensitive or responsive to violent acts in real life. This desensitization can contribute to a normalization of violence and reduce the perceived severity of violent behaviors. This can potentially lead to an increase in tolerance for violence in society. Incorrect choices: A: Has no effect on the increase of violence in society - This is incorrect because research has shown that exposure to media violence can have an impact on behavior. B: Assists individuals to distinguish appropriate behaviors from inappropriate behaviors - This is incorrect as exposure to violence in the media may blur the lines between appropriate and inappropriate behaviors. D: Broadens the viewer's knowledge about world happenings - This is incorrect as exposure to violence in the media may not necessarily lead to a broader understanding of world events, especially if the focus is on sensationalized or graphic content.
Question 5 of 5
The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior retirement community and has no close family. The nurse assesses mild dysphasia. The client cannot remember why he has a bandage. He thinks he is in the army and that it is 1950. Appropriate planning for the client should include:
Correct Answer: D
Rationale: The correct answer, D, is the most appropriate plan because it addresses the client's current needs and safety concerns. Firstly, assessing diet and meal preparation is important due to the client's dysphasia, which may impact their ability to eat safely. Secondly, assessing the environment for safety problems is crucial as the client has dementia and may be at risk of accidents. Lastly, referral to a dementia program is necessary to provide specialized care and support for the client's condition. Choices A, B, and C are incorrect because they do not directly address the specific needs of the client in terms of dementia, dysphasia, and safety concerns. They focus on unrelated interventions that are not as critical in this scenario.