ATI RN
Age Specific Care Questions
Question 1 of 5
Which instruction has priority when teaching a patient taking clozapine (Clozaril)?
Correct Answer: B
Rationale: The correct answer is B: Report sore throat and fever immediately. This is because clozapine can cause a serious condition called agranulocytosis, which is characterized by a dangerously low white blood cell count. Sore throat and fever can be early signs of this condition, so it is crucial to report them immediately to prevent serious complications. Avoiding unprotected sex (choice A) is important for overall health but is not directly related to clozapine use. Reducing foods high in polyunsaturated fats (choice C) is not a priority as it does not impact the safety or effectiveness of clozapine. Using over-the-counter preparations for rashes (choice D) is not advised as rashes can be a side effect of clozapine, and professional medical advice should be sought.
Question 2 of 5
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
Correct Answer: A
Rationale: The correct answer is A: Anticholinergic toxicity. The patient's symptoms of restlessness, disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and significant departure from recent presentation are classic signs of anticholinergic toxicity. Anticholinergic medications can lead to central nervous system and peripheral anticholinergic effects, causing confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate initial interventions to address the symptoms. Choices B, C, and D are incorrect because they do not align with the patient's symptoms and presentation. Choice B (Relapse of her psychosis) does not fully explain the physical symptoms such as hot and dry skin, dilated pupils, and disorientation. Choice C (Neuroleptic malignant syndrome) typically presents with muscle rigidity, hyperthermia, autonomic instability, and altered mental status, which are not completely consistent
Question 3 of 5
A 28-year-old female client was admitted 3 days ago after she ran nude through the streets shouting that she was the 'Queen of Hearts.' Since admission, the client remains delusional, shouts obscenities, and demonstrates loosely associated thoughts. Based on these data, the nurse should develop a nursing diagnosis of:
Correct Answer: C
Rationale: The correct answer is C: Disturbed thought processes. The client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disturbance in thought processes. This nursing diagnosis focuses on the client's cognitive functioning and perception of reality. A: Risk for violence is not the most appropriate diagnosis in this case as there is no direct evidence of the client being a risk to herself or others. B: Defensive coping does not address the client's specific symptoms of delusions and disorganized thinking. D: Impaired memory is not the most appropriate diagnosis as the client's symptoms are more indicative of a broader disturbance in thought processes rather than just memory deficits. Therefore, choice C is the most suitable nursing diagnosis based on the client's presentation of delusional behavior and disorganized thoughts.
Question 4 of 5
The mother of a client newly diagnosed with schizophrenia is a nurse. She unhappily tells the nurse on the unit, 'I've tried to be a good mother, but my daughter still developed schizophrenia. When I was in school, we were taught that it was the mother's fault if a child became schizophrenic. I wish I knew what I did wrong.' The response that would help the mother evaluate models explaining schizophrenia would be:
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Choice B is the correct answer because it provides the mother with new information that schizophrenia is biologic in nature, shifting the blame away from her. 2. This response helps the mother understand that her daughter's condition is not her fault, based on current scientific understanding. 3. By offering this information, the nurse helps the mother reevaluate her beliefs and perceptions about the causes of schizophrenia. 4. Choices A, C, and D do not address the mother's concerns directly or provide her with the necessary information to understand the biological basis of schizophrenia.
Question 5 of 5
An acutely psychotic individual diagnosed with schizophreniaform disorder at admission is immediately placed on daily doses of risperidone. A hospitalization of 8 days' duration has been authorized by the HMO. By what hospital day would the nurse expect to note that client was demonstrating beginning trust in the nurse and reduction in hallucinations and delusions?
Correct Answer: B
Rationale: The correct answer is B: Day 3 of hospitalization. At this point, the risperidone medication would have had sufficient time to begin exerting its therapeutic effects on the individual's symptoms of hallucinations and delusions. It typically takes a few days for antipsychotic medications like risperidone to reach therapeutic levels in the body and start alleviating psychotic symptoms. By day 3, the individual may start to demonstrate improved trust in the nurse due to the reduction in distressing symptoms. Incorrect options: A: Day of admission - It is unlikely to see significant improvement in symptoms and trust on the same day of admission. C: Day 5 of hospitalization - By this time, the medication would have likely already started showing some effects, and the individual would have had some time to build trust with the nurse. D: Day 7 of hospitalization - Waiting until day 7 might be too late to note beginning trust and significant reduction in symptoms, as the