ATI RN
Age Specific Patient Care Questions
Question 1 of 5
When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial personality disorder, the nurse recognizes that the following nursing diagnosis would be pertinent to his care:
Correct Answer: C
Rationale: Step-by-step rationale for choice C (Impaired social interaction) being the correct answer: 1. Antisocial personality disorder is characterized by a lack of regard for others and a pattern of violating their rights. 2. Individuals with this disorder often have difficulty forming and maintaining healthy relationships. 3. Impaired social interaction reflects the challenges the individual faces in relating to others. 4. This nursing diagnosis would address the core issue of social dysfunction in individuals with antisocial personality disorder. Summary of why the other choices are incorrect: A. Risk for self-mutilation - Not typically associated with antisocial personality disorder, more common in other mental health conditions. B. Disturbed personal identity - Not a primary concern in antisocial personality disorder, which is more about behavior than identity. D. Social isolation - While individuals with antisocial personality disorder may isolate themselves, impaired social interaction is a more direct and specific issue to address in their care.
Question 2 of 5
A patient with anorexia nervosa is being treated with refeeding. Which complication should the nurse monitor for during this phase?
Correct Answer: B
Rationale: The correct answer is B: Hypophosphatemia and cardiac arrhythmias. During refeeding in anorexia nervosa, there is a risk of rapid shifts in electrolytes, particularly phosphorus, leading to hypophosphatemia which can cause cardiac arrhythmias. This is a critical complication that the nurse should monitor for. Hyperkalemia and hyperglycemia (choice A) are less common in refeeding syndrome. Increased appetite and food cravings (choice C) are expected outcomes of refeeding, not complications. Dehydration and hypotension (choice D) are potential issues but are not specific to refeeding in anorexia nervosa.
Question 3 of 5
Which measure is advisable to take, considering that individuals with dramatic erratic personality disorders often have the ability to evade limits and manipulate others?
Correct Answer: A
Rationale: The correct answer is A: Plan frequent client-centered staff meetings. This measure is advisable as it promotes open communication, collaboration, and consistency in care. By holding regular meetings, staff can discuss concerns, share observations, and develop strategies to effectively manage individuals with erratic personality disorders. This approach helps in setting clear boundaries, identifying manipulative behaviors, and ensuring a unified team response. Summary: - Choice B: Practice take-down and restraint procedures is incorrect as it focuses on physical control rather than preventive strategies. - Choice C: Institute written or taped change-of-shift reports is incorrect as it lacks real-time communication and immediate response to potential issues. - Choice D: Rotate staff assignments so no one is responsible for the client for a prolonged period of days is incorrect as it may disrupt continuity of care and hinder the establishment of trust and rapport.
Question 4 of 5
A patient with antisocial personality disorder tells Nurse A, 'You're a much better nurse than Nurse B said you were.' The patient tells Nurse B, 'Nurse A's upset with you for some reason.' To Nurse C the patient states, 'You'd like to think you're perfect, but I've seen three of your mistakes this morning.' These comments can best be assessed as:
Correct Answer: D
Rationale: The correct answer is D: manipulative. The patient is using different strategies to manipulate each nurse's emotions and behavior for personal gain. In the first scenario, the patient is attempting to create a divide between Nurse A and Nurse B by praising Nurse A and implying Nurse B's incompetence. In the second scenario, the patient is trying to instigate conflict between Nurse A and Nurse B by falsely suggesting Nurse A's negative feelings towards Nurse B. In the third scenario, the patient is employing a manipulative tactic by undermining Nurse C's confidence and competence. These behaviors demonstrate a pattern of manipulation aimed at controlling and influencing the nurses' perceptions and actions. Choices A, B, and C do not accurately capture the manipulative intent behind the patient's actions.
Question 5 of 5
A patient with borderline personality disorder has cut her wrists. The physician orders daily dressing changes for the lacerations. The nurse performing this care should:
Correct Answer: B
Rationale: The correct answer is B: provide care in a matter-of-fact manner. This approach is important in treating patients with borderline personality disorder as it helps maintain boundaries and consistency, which are crucial for managing their condition. By being matter-of-fact, the nurse can prevent potential manipulation or reinforcement of maladaptive behaviors. Encouraging the patient to vent anger (choice A) may escalate the situation. Being overly sympathetic (choice C) can blur professional boundaries. Offering to listen to feelings (choice D) may reinforce the behavior and not address the underlying issues effectively.