ATI RN
Age Specific Care Questions
Question 1 of 5
The nursing diagnosis Rape-trauma syndrome is established for a rape victim in the emergency department. Select the most important outcome to achieve before discharging the patient!
Correct Answer: D
Rationale: The correct answer is D. Establishing a follow-up appointment with a rape victim advocate is crucial for ongoing support and recovery. It ensures the patient has access to necessary resources and assistance in coping with the trauma. Choice A focuses on emotional well-being but doesn't address long-term support. Choice B addresses memory but doesn't ensure ongoing care. Choice C only addresses physical symptoms, neglecting the emotional and psychological impact of the trauma. Thus, choice D is the most important outcome to achieve before discharging the patient to promote comprehensive care and support.
Question 2 of 5
A client, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to my husband, since he continues to abuse me.' The nurse is aware that the final decision to leave a batterer:
Correct Answer: B
Rationale: The correct answer is B: Is usually a gradual process that occurs over time. Rationale: 1. Leaving an abusive partner is a complex and difficult decision that often requires careful planning and support. 2. Victims may face various barriers such as financial dependence, emotional attachment, and fear of further violence. 3. It is rare for victims to abruptly leave without considering their safety and well-being. 4. The statement 'I probably should not keep going back' indicates a gradual realization and contemplation of leaving. Summary: A: The decision to leave is not solely based on serious injury; victims may leave before any significant harm occurs. C: Approval from the church may influence the victim's decision but is not a determining factor. D: Leaving an abusive partner should not require the batterer's permission; it is a personal choice made by the victim.
Question 3 of 5
A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacantly. You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
Correct Answer: C
Rationale: The correct answer is C: Impaired home maintenance, disturbed thought process, impaired verbal communication. Rationale: 1. Impaired home maintenance: The client is unable to take care of herself and her living environment due to the need for assistance in shopping, meal preparation, and finances. 2. Disturbed thought process: The client's vacant stare and inability to learn new tasks suggest cognitive impairment or confusion. 3. Impaired verbal communication: The client's lack of verbal interaction and reliance on her sister for assessment data indicate difficulties in expressing herself. Summary: A: Pain, self-care deficits, situational low self-esteem - Pain is not mentioned in the scenario, and the client's issues go beyond self-care deficits and low self-esteem. B: Anxiety, self-care deficits, disturbed thought processes - While anxiety and disturbed thought processes may be present, impaired home maintenance and impaired verbal communication are more appropriate diagnoses based on the scenario. D: Disturbed body image, anxiety, pain - Disturbed
Question 4 of 5
A client has been diagnosed with Alzheimer's disease, stage 1. The nurse would expect to help the family plan measures to assist the client with:
Correct Answer: A
Rationale: The correct answer is A: Recent memory loss. In stage 1 of Alzheimer's disease, the primary symptom is mild memory loss, particularly with recent events and information. The nurse would help the family plan measures to assist the client by implementing strategies to support memory, such as setting reminders, organizing daily routines, and using memory aids. Choice B, catastrophic reactions, is more commonly associated with later stages of the disease. Choice C, progressive gait disturbances, is not a typical symptom of stage 1 Alzheimer's. Choice D, perseveration, involves the repetition of a particular response or behavior and is not a primary concern in stage 1 Alzheimer's disease.
Question 5 of 5
A 75-year-old male client is brought to the clinic by his son. The son states, 'Ever since Mom died, Dad hasn't been the same. At first he just seemed sad, but now he seems to get mixed up about everything.' The nurse is aware that based on the client's history, the source of confusion is most likely:
Correct Answer: B
Rationale: Correct Answer: B - Depression from the loss of his wife Rationale: Given the client's recent loss of his wife and subsequent changes in behavior, the most likely cause of his confusion is depression. Depression can manifest as cognitive impairment in older adults, leading to symptoms such as confusion and memory problems. Additionally, grief and loss can exacerbate depressive symptoms in elderly individuals, further contributing to cognitive difficulties. Summary of other choices: A: Dementia - Dementia typically presents with gradual cognitive decline over time, not a sudden onset following a specific event like the loss of a loved one. C: Hypoxia of the brain - Hypoxia would likely present with more acute symptoms and physical signs, such as shortness of breath or cyanosis. D: Delirium from medications - Delirium is characterized by acute onset and fluctuating course, often related to medication changes or other medical conditions, rather than an emotional trigger like grief.