ATI RN
Concept of Family Centered Care Questions
Question 1 of 5
The nurse is preparing to read the Mantoux tuberculin skin test placed on the forearm of a patient with HIV. Which finding should the nurse report as a positive test for this patient?
Correct Answer: D
Rationale: The correct answer is D (5 mm) for a positive Mantoux test in a patient with HIV. In HIV-positive individuals, a positive test is considered when the induration is ≥5 mm. This is because the immune system may be compromised, leading to a delayed immune response. Choices A, B, and C (2 mm, 3 mm, 4 mm) are not considered positive for HIV-positive individuals due to their weakened immune system, requiring a larger induration size to indicate a positive test.
Question 2 of 5
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, 'Somebody tied me up with ropes.' The patient is experiencing:
Correct Answer: A
Rationale: The correct answer is A: illusion. An illusion is a misinterpretation of a real external stimulus. In this case, the patient is misperceiving the traction as ropes due to the altered mental state from intoxication. It is a sensory distortion based on a real object. Delusion (B) is a fixed false belief, not related to sensory perceptions. Hallucinations (C) are false sensory perceptions without external stimulus. Hypnagogic phenomenon (D) refers to sensory experiences during the transition from wakefulness to sleep, not applicable here.
Question 3 of 5
A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse’s best response?
Correct Answer: A
Rationale: The correct answer is A: "It is a self-help group with the goal of sobriety." This is the best response because Alcoholics Anonymous (AA) is indeed a self-help group focused on achieving and maintaining sobriety through shared experiences and support. Choice B is incorrect because AA is not led by a psychiatrist but rather by individuals who are also in recovery. Choice C is incorrect as AA does not focus on learning about drinking but rather on supporting recovery. Choice D is incorrect as AA does not advocate for punishment but rather emphasizes compassion and understanding towards individuals struggling with alcohol addiction.
Question 4 of 5
When working with a patient beginning treatment for alcohol dependence, what is the nurse’s most therapeutic approach?
Correct Answer: A
Rationale: The correct answer is A: Empathetic, supportive. This approach establishes trust, shows understanding, and promotes open communication. Empathy helps build a therapeutic relationship, which is crucial in treating alcohol dependence. Being supportive encourages the patient to feel safe and willing to discuss their issues. Strong, confrontational (B) may lead to resistance and defensiveness. Skeptical, guarded (C) can create barriers and hinder progress. Cool, distant (D) may make the patient feel isolated and unsupported. Overall, empathy and support create a positive and collaborative therapeutic environment.
Question 5 of 5
Select the nursing intervention necessary after administering naloxone (Narcan) to a patient with an opiate overdose.
Correct Answer: A
Rationale: The correct answer is A: Monitor the airway and vital signs every 15 minutes. After administering naloxone to a patient with an opiate overdose, it is crucial to monitor the patient's airway and vital signs regularly to assess for respiratory depression, potential re-sedation, and other adverse effects of naloxone. This intervention ensures the patient's safety and allows for prompt detection and management of any complications. Choice B is incorrect because inserting a nasogastric tube and testing gastric pH is not indicated after naloxone administration for opiate overdose. Choice C is incorrect as treating hyperpyrexia with cooling measures is not a priority intervention in this scenario. Choice D is also incorrect as inserting an indwelling urinary catheter is not necessary after administering naloxone for opiate overdose.