ATI RN
Age Specific Nursing Care Questions
Question 1 of 5
Which neurological deficit(s) would the nurse be most likely to encounter when assessing a patient diagnosed with schizophrenia?
Correct Answer: D
Rationale: The correct answer is D because in schizophrenia, patients may exhibit increased blinking and impaired fine motor skills due to medication side effects or neurological changes. Weakness, loss of function, droopy eyelids with reddened cornea, paralysis, and diminished reflexes are not commonly associated with schizophrenia. It is crucial for the nurse to recognize these neurological deficits to provide appropriate care and support for the patient.
Question 2 of 5
The client has been taking lithium and fluoxetine (Prozac) for almost a week. During today's assessment, the nurse notes a temperature of 39°C, muscle rigidity, and confusion. The client's signs and symptoms suggest:
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). This is indicated by the client's elevated temperature, muscle rigidity, and confusion, which are classic symptoms of NMS. NMS is a serious, potentially life-threatening condition associated with the use of antipsychotic medications like lithium and fluoxetine. The onset of NMS is often rapid and can lead to severe complications if not treated promptly. Dystonic reactions (choice A) involve sudden and involuntary muscle contractions, which are not consistent with the client's symptoms. Bradykinesic side effects (choice B) refer to slowed movements, which are not present in this case. Extrapyramidal side effects (choice C) typically include symptoms like tremors, stiffness, and restlessness, but do not encompass the combination of symptoms seen in NMS.
Question 3 of 5
A patient is currently in an abusive relationship with the father of her only child and tells a nurse that her partner 'is really sorry for hitting me and wants to come back and be part of the family again.' The nurse should provide which intervention?
Correct Answer: B
Rationale: The correct answer is B: Identify groups that focus on treatment for individuals who are abusive. This intervention is appropriate because it addresses the root cause of the abusive behavior, which is the partner's abusive tendencies. By connecting the abuser to groups that specialize in treating abusive behavior, there is a chance for change and rehabilitation. A: Sharing with the patient that abusers seldom voluntarily stop abusing may not be helpful as it does not provide a proactive solution to address the abusive behavior. C: Telling the patient to continue the relationship and focus on minimizing the abuse is dangerous as it normalizes and enables the abusive behavior, putting the patient at further risk. D: Threatening the patient's partner with reporting to the police may escalate the situation and put the patient at higher risk of harm. It does not address the underlying issue of the partner's abusive behavior.
Question 4 of 5
A community mental health nurse is assigned to investigate the frequent school absences of an 11-year-old child. The nurse finds the child home alone, caring for his 1- and 3-year-old siblings. The house is cluttered and dirty, and both parents are at work. The child tells the nurse that whenever his mother is called to work at her part-time job, he must watch the kids because the family cannot afford a babysitter. Based on the information obtained thus far, what preliminary assessment can be made?
Correct Answer: B
Rationale: The correct answer is B: The child and his siblings are experiencing neglect. Neglect is defined as failure to provide for a child's basic needs, such as supervision, food, shelter, and medical care. In this scenario, the child is left alone to care for his younger siblings, indicating a lack of appropriate supervision and care from the parents. The house being cluttered and dirty further suggests neglect in terms of living conditions. Choice A is incorrect because the child is not coping well; rather, he is forced into a caretaker role beyond his developmental capacity. Choice C is incorrect as there is no information provided to suggest sexual abuse. Choice D is incorrect as there is no evidence of physical abuse in the scenario.
Question 5 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 nursing diagnosis is "Disturbed thought processes" (C) because the client's behavior of being delusional, shouting obscenities, and demonstrating loosely associated thoughts indicates a disruption in their ability to think clearly and logically. This diagnosis reflects the client's cognitive dysfunction and disorganized thinking patterns. Choice A (Risk for violence) is incorrect because the client's behavior does not directly suggest a risk for violence towards others or themselves. Choice B (Defensive coping) is incorrect as the client's behavior is not indicative of using defensive mechanisms to cope with stress or anxiety. Choice D (Impaired memory) is incorrect as the client's symptoms are more indicative of thought processing issues rather than memory deficits. In summary, the client's presentation aligns closely with symptoms of disturbed thought processes, making it the most appropriate nursing diagnosis in this case.