ATI RN
Concept of Family Health Nursing Care Questions
Question 1 of 5
The nurse is contributing to a nutrition and hydration teaching plan for a patient who has AIDS. What recommendations should the nurse include in this plan? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: Soft cheeses may contain harmful bacteria that can be dangerous for individuals with compromised immune systems like AIDS patients. The nurse should recommend avoiding soft cheeses to prevent foodborne illnesses. Soft cheeses are typically made from unpasteurized milk, which increases the risk of bacterial contamination. AIDS patients have weakened immune systems, making them more susceptible to infections. Summary of Other Choices: B: Avoiding Caesar salad is not necessarily a specific recommendation for AIDS patients unless there are additional factors to consider, such as the presence of certain raw ingredients that may pose a risk to the patient. C: Avoiding public drinking fountains is a general hygiene recommendation that may apply to all individuals, not specific to AIDS patients. D: Avoiding all beers and soft drinks is not a specific recommendation for AIDS patients unless there are additional factors such as alcohol interactions with medication or sugar content affecting blood sugar levels.
Question 2 of 5
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
Correct Answer: C
Rationale: The correct answer is C: Provide one-on-one supervision. This intervention has priority because the patient is experiencing hallucinations, agitation, and anxiety, which can pose a risk to their safety. One-on-one supervision ensures constant monitoring and immediate intervention if the patient's condition deteriorates. Checking the patient every 15 minutes (A) may not provide timely intervention. Encouraging fluid intake (B) is important but not the priority in this situation. Keeping the room dimly lit (D) may not address the patient's hallucinations and agitation adequately.
Question 3 of 5
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, 'After discharge, I’m sure everything will be just fine.' Which remark by the nurse will be most helpful to the spouse?
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the spouse's optimism while also gently highlighting the potential challenges that may arise during the recovery process. By pointing out that new problems may emerge as the patient adjusts to a life without alcohol, the nurse prepares the spouse for potential difficulties and encourages realistic expectations. Choice A is incorrect because it only acknowledges the spouse's support without addressing the potential challenges ahead. Choice C is incorrect because it focuses solely on stress avoidance rather than preparing for the overall adjustment process. Choice D is incorrect because it emphasizes monitoring the patient's behavior rather than addressing the spouse's outlook and potential struggles.
Question 4 of 5
A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, 'I feel terrible.' Which analysis is correct?
Correct Answer: C
Rationale: The correct analysis is C: Symptoms of opiate withdrawal are present. The patient's presentation of muscle aches, abdominal cramps, gooseflesh, and feeling terrible are classic symptoms of opiate withdrawal. Naloxone, as an opioid antagonist, reversed the effects of heroin leading to withdrawal symptoms. This is a typical response seen in patients who have been given naloxone to counteract opioid overdose. Choices A and B are incorrect as they do not align with the patient's clinical presentation and pharmacological understanding. Choice D is also incorrect as there is no indication that the patient has resumed heroin use.
Question 5 of 5
Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis?
Correct Answer: B
Rationale: The correct answer is B: Disturbed thought processes. Both patients with paranoid schizophrenia and amphetamine-induced psychosis commonly experience altered thinking patterns, hallucinations, and delusions. This nursing diagnosis addresses the cognitive disruptions present in both conditions. Incorrect choices: A: Powerlessness - This diagnosis refers to a lack of control over one's life situation, which may not be a primary concern for these patients. C: Ineffective thermoregulation - This diagnosis relates to the body's ability to maintain temperature, which is not typically affected in these conditions. D: Impaired oral mucous membrane - This diagnosis is related to issues with the mouth's lining and is not typically associated with paranoid schizophrenia or amphetamine-induced psychosis.