ATI RN
Population Based Care Questions
Question 1 of 5
Which of these assessment findings would indicate that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault?
Correct Answer: B
Rationale: The correct answer is B because exhibiting confusion, restlessness, and fear when left alone aligns with the acute stage of sexual assault trauma. During this stage, victims often experience shock, disbelief, and heightened anxiety. This behavior reflects immediate emotional distress and trauma response. Choice A indicates characteristics of control and demanding behavior, which are not typically seen in the acute stage. Choice C suggests using profanity, which may vary based on individual coping mechanisms. Choice D indicates a specific trigger response on the anniversary, suggesting a later stage of processing trauma, not the acute phase.
Question 2 of 5
A victim of partner abuse, parent of one child, describes the partner as someone who is easily frustrated and more likely to be abusive after experiencing an event in which self-esteem is challenged. The most recent episodes of violence were related to feeling 'upset' over a job loss. What type of therapy would provide the greatest help to the victim?
Correct Answer: A
Rationale: The correct answer is A: Individual therapy. In this scenario, individual therapy would be most beneficial because it allows the victim to focus on healing and developing coping strategies for dealing with the abuse and rebuilding self-esteem. Addressing the victim's psychological well-being and empowering them to recognize and address the abusive behavior is crucial. Group therapy (B) may not provide the necessary individualized support. Couples therapy (C) could potentially put the victim at further risk of harm. Family therapy (D) may not address the specific dynamics of the abusive relationship.
Question 3 of 5
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
Correct Answer: B
Rationale: The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance. A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him. C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs. D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
Question 4 of 5
A patient received maintenance doses of fluphenazine decanoate (Prolixin Decanoate) 25 mg IM every 2 weeks for 2 years. The clinic nurse notes the patient is grimacing and seems to be constantly smacking her lips. On the next clinic visit, the patient's neck and shoulders twist in a slow, snakelike motion. The nurse should suspect the presence of ______ and should ______.
Correct Answer: B
Rationale: Step 1: The patient is showing signs of abnormal movements like lip smacking, grimacing, and snakelike motions, which are indicative of tardive dyskinesia (TD). Step 2: TD is a side effect of long-term antipsychotic use, such as fluphenazine decanoate. Step 3: The Abnormal Involuntary Movement Scale is a validated tool to assess the severity of TD. Step 4: Administering the Abnormal Involuntary Movement Scale will help confirm the diagnosis of TD. Step 5: Prompt recognition of TD is crucial as it may be irreversible and can worsen over time if not addressed. Summary: - A: Agranulocytosis is a condition characterized by low white blood cell count, not related to the patient's symptoms. - C: Tourette's syndrome presents with different symptoms and requires specialized evaluation. - D: Anticholinergic effects do not typically manifest as the described
Question 5 of 5
A nurse observes a patient who is sitting alone in a room put hands over both ears and vigorously shake her head as though saying, 'No.' Later the patient cries and mutters, 'You don't know what you're talking about! Leave me alone.' What assessment should the nurse attempt to validate?
Correct Answer: C
Rationale: The correct answer is C because the patient's behavior indicates a possible experience of auditory hallucinations. The patient covering both ears and shaking her head could be an attempt to block out voices or sounds she is hearing. The subsequent crying and muttering could be a response to these hallucinations. Choice A is incorrect because the patient's behavior does not necessarily indicate a desire for attention. Choice B is incorrect because the patient's emotional expression is not the primary focus of the behavior. Choice D is incorrect because negative symptoms of schizophrenia typically involve a decrease in emotional expression or motivation, which is not evident in this scenario.