ATI RN
Age Specific Patient Care Questions
Question 1 of 5
The nurse is interviewing a client who presents with a dislocated shoulder. She demonstrates signs of anxiety and poor eye contact and turns to her partner for answers, allowing him to speak for her. The nurse asks the partner to go to the admitting office to give insurance information. While the partner is out of the room, which question is most important to ask?
Correct Answer: A
Rationale: Step 1: By asking how the shoulder dislocation occurred, the nurse can assess the mechanism of injury and potential risk factors for further harm. Step 2: Understanding the cause can guide treatment decisions and prevent future injuries. Step 3: This question is crucial for providing appropriate care and ensuring the client's safety. Summary: Option A is the correct answer as it directly relates to the client's current condition and allows the nurse to gather essential information for effective care. Options B and C are not as pertinent at this moment, and option D is incorrect as gathering information from the client is essential in this situation.
Question 2 of 5
A 72-year-old widow has just returned home after 2 weeks in the hospital after a fall. She lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the visiting nurse stopped by 2 days after discharge, he found the woman confused and disoriented, with an unsteady gait. The patient asks him who he is and why he is there. The nurse correctly deduces that the most likely cause for the changes seen in the patient is:
Correct Answer: A
Rationale: The correct answer is A: Delirium. The patient's sudden onset of confusion, disorientation, and unsteady gait after discharge from the hospital suggests delirium. Delirium is an acute change in mental status with fluctuating symptoms, often caused by underlying medical conditions, medications (such as diazepam), or environmental factors. In this case, the recent hospitalization, multiple medications, and potential stressors like living alone and recent fall increase the risk for delirium. Incorrect choices: B: Dementia is a chronic, progressive condition characterized by memory loss and cognitive decline. The sudden onset of symptoms in this case is not consistent with dementia. C: Drug toxicity could be a possibility given the patient's medication list, but delirium is a more likely explanation due to the acute onset of symptoms post-hospitalization. D: None of the above is incorrect because delirium is the most likely cause based on the patient's presentation and risk factors.
Question 3 of 5
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
Correct Answer: D
Rationale: Rationale: 1. Patient's diagnosis indicates coping issues, not anger expression or self-esteem. 2. Patient's coping mechanism involves overeating and vomiting, not diet. 3. Outcome should focus on coping skills improvement, not unrelated goals. 4. None of the choices address the root issue of coping with loneliness and isolation. 5. Thus, the correct answer is D, as none of the options directly address the patient's ineffective coping mechanism.
Question 4 of 5
The nurse who is caring for a 23-year-old client with bulimia knows that the most common method of purging to monitor this client for is:
Correct Answer: A
Rationale: The correct answer is A: Vomiting. In bulimia, vomiting is the most common method of purging after binge eating to control weight. Monitoring for signs of vomiting, such as frequent trips to the bathroom after meals or presence of swollen salivary glands, is crucial. Starvation (B) is not a method of purging in bulimia but rather a consequence of restriction in anorexia nervosa. Excessive enema use (C) is not a common method of purging in bulimia and can be harmful. Therefore, the correct choice is A as it aligns with the typical behavior of individuals with bulimia.
Question 5 of 5
The nurse is evaluating a patient with bulimia nervosa. The most appropriate action is to:
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to avoid purging after meals. This is the most appropriate action because it addresses the harmful purging behavior associated with bulimia nervosa. By encouraging the patient to avoid purging, the nurse can help prevent serious health consequences such as electrolyte imbalances and damage to the esophagus. Option A is incorrect because assigning a strict dietary plan may exacerbate the patient's unhealthy relationship with food and contribute to feelings of guilt and shame. Option B is incorrect as monitoring for physical symptoms of starvation may not directly address the underlying issue of purging behavior. Option D is also incorrect as providing emotional support alone may not effectively address the harmful purging behavior.