ATI RN
Age Specific Care Questions
Question 1 of 5
Which statement is most likely from a patient with anorexia nervosa?
Correct Answer: A
Rationale: The correct answer is A because it reflects a distorted body image common in anorexia nervosa. Patients with anorexia nervosa often perceive themselves as overweight or unattractive despite being underweight. Choice B is positive and unrelated to body image. Choice C is a factual statement about weight, not necessarily indicative of anorexia. Choice D introduces an external factor (mother's opinion) which is not typically a primary concern for individuals with anorexia nervosa.
Question 2 of 5
Police bring a patient to the mental health unit. The patient was directing traffic and shouting rhymes on a busy city street. The patient's spouse reports that the patient has not slept or eaten for 3 days. Which assessment findings have priority concern for this patient's plan of care?
Correct Answer: B
Rationale: The correct answer is B. Hyperactivity, not eating, and not sleeping are priority concerns as they indicate potential mania or hypomania, which can be dangerous and require immediate intervention. Not eating and sleeping for days can lead to physical and mental health complications. Pressured speech and grandiosity (Choice A) are symptoms of mania but not as urgent as lack of eating and sleeping. Poor concentration and decision making (Choice C) are also symptoms of mania, but not as immediately concerning as the lack of eating and sleeping. Insulting behavior (Choice D) is not a priority concern for immediate intervention in this scenario.
Question 3 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 4 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 5 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.