ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
Correct Answer: A
Rationale: The correct answer is A: "This disorder responds well to treatment and, with follow-up, may not recur." Rationale: 1. Paranoid schizophrenia typically responds well to treatment, especially with early intervention. 2. With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and lead fulfilling lives. 3. Follow-up care and support are crucial in maintaining stability and preventing relapses. Summary of why other choices are incorrect: B: All types of schizophrenia are chronic relapsing disorders - This is not accurate as outcomes can vary depending on the subtype of schizophrenia. C: Outcomes are poor related to client prehospital disorganization - This statement is too general and does not specifically address the prognosis of paranoid schizophrenia. D: The usual outcome is that only partial remission is achieved - This is not always the case, as many individuals with paranoid schizophrenia can achieve full remission with appropriate treatment.
Question 2 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 3 of 5
A patient, aged 77 years, has Alzheimer's disease. She goes to day care during the week and is otherwise cared for by her daughter and grandchildren. The nurse at the day care center noticed multiple bruises on the patient's palms, elbows, and buttocks. When the daughter arrived to pick her up, the nurse discussed her observations. The daughter became defensive and said that her mother was very difficult to manage. She stated, "My mother is not my mother anymore. She is confused, and she wanders all night. We have to watch her constantly. Last night I fell asleep, and she fell down the stairs. Sometimes she cannot recognize me and accuses me of trying to poison her. I can't concentrate at work, and it's wrecking the family. Sometimes I just cannot bear it." Which nursing diagnosis would be most important to address for this family?
Correct Answer: D
Rationale: The correct nursing diagnosis to address in this scenario is D: Caregiver role strain related to increased care needs. This is the most important as it focuses on the daughter's challenges and emotional burden due to her mother's condition. The daughter's statements reveal feelings of overwhelm, guilt, and exhaustion, which are key indicators of caregiver role strain. By addressing this nursing diagnosis, the healthcare team can provide support and resources to help the daughter cope with the demands of caring for her mother. Choice A (Knowledge deficit pertaining to dementia) is not the most important in this situation as the daughter's issue is not lack of knowledge but rather emotional stress. Choice B (Grieving related to mother's deterioration) is not the priority as addressing the daughter's emotional strain is more urgent than addressing grief. Choice C (Risk for injury related to cognitive impairment) is also important but not as immediate as addressing the caregiver's emotional well-being.
Question 4 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 5 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.