ATI RN
Age Specific Care Questions
Question 1 of 5
What is the most effective strategy for preventing relapse in a patient with anorexia nervosa?
Correct Answer: B
Rationale: The correct answer is B because offering therapy to address both physical and emotional factors is the most effective strategy for preventing relapse in a patient with anorexia nervosa. This approach helps the patient develop coping skills, explore underlying issues, and learn healthier ways to manage emotions and stress. By addressing both physical and emotional factors, the patient can build a strong support system, improve self-esteem, and work towards a sustainable recovery. Choice A is incorrect because providing a rigid, inflexible meal plan with strict weight goals may increase anxiety and reinforce harmful behaviors associated with anorexia nervosa. Choice C is incorrect as encouraging the patient to lose weight to maintain control can perpetuate the disorder and increase the risk of relapse. Choice D is incorrect because focusing on body image improvement before addressing nutrition neglects the essential aspect of nutrition in recovery and may lead to distorted perceptions of health.
Question 2 of 5
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy." A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
Question 3 of 5
A patient experiencing delirium secondary to corticosteroid toxicity is manifesting paranoid thinking and noisy, assaultive behavior. The patient is currently pacing the hall and shouting. A nurse has placed a call to the physician and is anticipating the following order:
Correct Answer: A
Rationale: The correct answer is A: the use of supervised restraints. In this situation, the patient is displaying agitated and assaultive behavior, posing a risk to themselves and others. Supervised restraints are necessary to ensure the safety of the patient and healthcare providers until the effects of corticosteroid toxicity subside. Restraints should only be used as a last resort when other interventions have failed. Choice B: A loading dose of phenytoin is incorrect because phenytoin is not indicated for managing delirium secondary to corticosteroid toxicity. Choice C: A small dose of prednisone is incorrect because adding more corticosteroids would exacerbate the toxicity and worsen the delirium. Choice D: An IV dose of thiamine is incorrect as thiamine is used to treat thiamine deficiency, not corticosteroid toxicity-induced delirium.
Question 4 of 5
A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is 2.7 mg/dL. Which nursing diagnosis applies?
Correct Answer: D
Rationale: The correct answer is D: Imbalanced nutrition: less than body requirements related to refusal to eat, as evidenced by loss of 25% of body weight and hypokalemia. Rationale: 1. Anorexia nervosa involves severe restriction of food intake, leading to significant weight loss and malnutrition. 2. The patient's history of virtually stopping eating and losing 25% of body weight aligns with the nursing diagnosis of imbalanced nutrition. 3. Hypokalemia (low serum potassium level) is common in patients with anorexia nervosa due to inadequate intake or purging behaviors. 4. The other choices are incorrect because they do not match the patient's specific presentation of anorexia nervosa and hypokalemia.
Question 5 of 5
A nursing intervention that will be planned to occur early in the nurse-patient relationship with a client with an eating disorder is:
Correct Answer: A
Rationale: The correct answer is A: formulating a nurse-client contract. This intervention is essential early in the nurse-patient relationship with a client with an eating disorder because it establishes clear boundaries, roles, and expectations. By creating a contract, both the nurse and the client can communicate openly about their goals, responsibilities, and treatment plan. This helps build trust, promotes collaboration, and provides a framework for the therapeutic relationship. Choices B, C, and D are incorrect: B: Using confrontation to attack denial may be counterproductive and harmful in the early stages of the relationship as it can lead to resistance and damage trust. C: Placing the client in a therapeutic group may be beneficial at a later stage but not necessarily an appropriate early intervention when individual needs should be addressed first. D: Attacking enmeshment by separating client and family is not a suitable early intervention as it may cause distress and disrupt important support systems.