ATI RN
Population Specific Care Questions
Question 1 of 5
Which finding for a patient with an eating disorder most clearly indicates the need for hospitalization?
Correct Answer: B
Rationale: The correct answer is B because urine output less than 30 mL/hr indicates severe dehydration and compromised kidney function, which can lead to organ failure. Hospitalization is necessary for immediate fluid resuscitation and monitoring. Option A is indicative of malnutrition but does not directly signify acute medical complications. Option C suggests hypokalemia, which can be managed on an outpatient basis. Option D, a low pulse rate, may be a sign of bradycardia but typically does not require immediate hospitalization unless accompanied by other severe symptoms.
Question 2 of 5
The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?
Correct Answer: B
Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline. Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms. Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome. Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome. Summary: - Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome. - Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention. - Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.
Question 3 of 5
A patient with schizophrenia is admitted to the psychiatric unit in an acutely disturbed, violent state. He is given several doses of haloperidol (Haldol) and becomes calm and approachable. During rounds the nurse notices the patient has his head rotated to one side in a stiffly fixed position. His lower jaw is thrust forward and he appears severely anxious. The patient has _____, and the nurse should _____.
Correct Answer: A
Rationale: The correct answer is A: A dystonic reaction"¦administer PRN IM benztropine (Cogentin). This patient is exhibiting symptoms of acute dystonia, a extrapyramidal side effect of haloperidol. Dystonic reactions are characterized by sustained muscle contractions causing abnormal postures. Benztropine is an anticholinergic medication that helps alleviate these symptoms by blocking the neurotransmitter acetylcholine. Administering benztropine is the appropriate treatment for acute dystonia. Summary of other choices: B: Tardive dyskinesia"¦seek a change in the drug or its dosage - Tardive dyskinesia is a side effect that occurs after long-term antipsychotic use, not acutely like in this case. C: Waxy flexibility"¦continue treatment with antipsychotic drugs - Waxy flexibility is a symptom of catatonia, not a side effect of antipsychotic medications
Question 4 of 5
A 32-year-old client with an admitting diagnosis of catatonic schizophrenia has been mute and motionless for 2 days. The priority nursing diagnosis is:
Correct Answer: A
Rationale: The correct answer is A: Risk for deficient fluid volume. The priority nursing diagnosis in this case is to address the client's physical needs to ensure their safety and well-being. The client's mutism and immobility put them at risk for dehydration and malnutrition. By prioritizing the risk for deficient fluid volume, the nurse can address the immediate physiological needs of the client. Choice B: Impaired physical mobility is incorrect because while the client is motionless, the immediate concern is addressing the risk of dehydration. Choice C: Impaired social interaction is incorrect as addressing social interaction is not the priority when the client's physical needs are not being met. Choice D: Ineffective coping is incorrect because the client's presentation is indicative of a more urgent physical need for hydration and nutrition.
Question 5 of 5
A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority?
Correct Answer: B
Rationale: The correct answer is B: Assessing the client for physical problems. This is the initial priority because the client's muteness and motionless state could be due to an underlying physical issue that needs immediate attention, such as dehydration, malnutrition, or infection. By assessing for physical problems first, the nurse can rule out any urgent medical concerns before addressing the client's mental health needs. A: Orienting the client to the unit - While important, this can be done after addressing any physical problems. C: Establishing a nonthreatening relationship - Also essential, but assessing physical health takes precedence. D: Reinforcing reality with the client - Not the immediate priority; physical assessment should come first.