ATI NUR 135 Exam 1

Correct Answer: A) Hypertension

Explanation

Anxiety disorders, especially when chronic, can lead to hypertension (high blood pressure). Anxiety triggers the body's "fight or flight" response, which results in the release of stress hormones like adrenaline and cortisol. These hormones cause the heart rate to increase, blood vessels to constrict, and blood pressure to rise. Over time, the persistent stress and anxiety can result in sustained high blood pressure, contributing to the development of hypertension.

Why the Other Options Are Incorrect:

B) Type 2 diabetes

While stress and anxiety can contribute to lifestyle factors (such as poor eating habits or lack of exercise) that might increase the risk of type 2 diabetes, anxiety itself does not directly cause this condition. However, there is evidence to suggest that chronic stress can have an indirect effect on the development of diabetes by affecting glucose metabolism.

C) Hypothyroidism

Hypothyroidism, or an underactive thyroid, is not directly related to anxiety disorders. Although stress can affect the body’s overall function, it does not specifically cause the thyroid gland to become underactive. Hypothyroidism is typically related to autoimmune diseases or issues with the thyroid itself.

D) Asthma

Anxiety can exacerbate asthma symptoms, especially in individuals who already have asthma, but anxiety does not directly cause asthma. Asthma is a chronic condition related to airway inflammation and is typically triggered by environmental factors or allergens. While anxiety may trigger an asthma attack, it is not a direct cause of the disease.

Summary:

A potential complication of anxiety disorder is hypertension, as the body's stress response leads to increased heart rate and blood pressure. Chronic anxiety can contribute to sustained high blood pressure, increasing the risk of cardiovascular problems. The other options listed are not directly caused by anxiety disorders, though they may be influenced by stress or anxiety indirectly.

Correct Answer: A. Factitious disorder

Explanation

Factitious disorder is a mental health condition in which an individual intentionally fabricates or induces physical or psychological symptoms in themselves (or in another person, if imposed on another) with the primary aim of assuming the sick role and receiving medical attention. These individuals go to great lengths to deceive healthcare providers, often undergoing unnecessary procedures or hospitalizations. Importantly, the motivation is psychological, not for tangible gain.

Why the Other Options Are Incorrect:

B. Conversion disorder

Also known as Functional Neurological Symptom Disorder, this involves involuntary neurological symptoms (e.g., paralysis, seizures) that cannot be explained by medical evaluation. Unlike factitious disorder, the symptoms are not intentionally produced.

C. Somatic symptom disorder

In this disorder, the person experiences genuine physical symptoms that cause distress or dysfunction, but these are not intentionally fabricated. The individual truly believes they are ill, even if there is no clear medical cause.

D. Malingering

Malingering involves intentional symptom fabrication like factitious disorder, but the motivation is external, such as obtaining drugs, avoiding work, or receiving financial compensation. In contrast, factitious disorder lacks these external incentives.

Summary:

The nurse recognizing that a patient intentionally deceives providers to receive unnecessary treatment without external gain is observing factitious disorder, where the primary motivation is to assume the role of a patient.

Correct Answers:

A. Identifying patients using both name and date of birth before drawing blood.

B. Sitting with the patient diagnosed with an eating disorder during meals.

D. Performing a medication history assessment on each new patient.

E. Using appropriate hand washing technique at all times.

Explanation

A. Identifying patients using both name and date of birth before drawing blood.

The Joint Commission’s National Patient Safety Goals (NPSGs) emphasize the importance of accurate patient identification to prevent errors in treatment, medication administration, and lab testing.

B. Sitting with the patient diagnosed with an eating disorder during meals.

Preventing harm and ensuring patient safety is a key goal. Patients with eating disorders, particularly anorexia nervosa or bulimia nervosa, are at risk for purging behaviors or refusal to eat. Supervised meals help ensure proper nutrition and prevent harmful behaviors.

D. Performing a medication history assessment on each new patient.

Medication reconciliation is a major NPSG to prevent medication errors, adverse drug interactions, and ensure safe and appropriate prescriptions.

E. Using appropriate hand washing technique at all times.

 Hand hygiene is a top priority for infection control, reducing the spread of hospital-acquired infections (HAIs).

Explanation of the Incorrect Answer:

C. Administering the Beck Scale on each patient at the time of admission.

While screening for depression and suicide risk is important, the Beck Depression Inventory (BDI) is not specifically mentioned in the National Patient Safety Goals. Instead, the focus is on universal suicide risk screening and early intervention, but not on the requirement of a specific tool like the Beck Scale.

Summary:

The correct interventions align with National Patient Safety Goals, focusing on accurate patient identification, infection prevention, medication safety, and monitoring high-risk patients. The Beck Scale, while useful, is not explicitly required under the safety goals.

The correct answer is Self-Esteem.

Explanation:

Self-Esteem refers to the need to feel good about oneself and believe that others hold one in high regard. It is an individual's overall sense of self-worth or personal value.

Why the Other Options Are Incorrect:

Local Adaptation Syndrome (LAS): LAS is a concept within the stress response that describes localized responses to stress, typically at the site of injury or infection, rather than being about an individual's self-perception or the need to feel good about oneself.

Reflective Practice: Reflective practice involves thinking critically about one's actions, learning from experiences, and improving professional practices. While it can enhance self-awareness, it does not directly relate to the need for positive self-regard.

Stress: Stress is a physiological and psychological response to demands or threats (stressors). It is not about the need to feel good about oneself but rather a reaction to external or internal pressures.

Summary:

Self-esteem is the correct term for the need to feel good about oneself and believe that others hold one in high regard. The other options pertain to different concepts related to health and behavior but do not directly address the sense of self-worth or esteem.

Correct Answer: C) 95-105 mEq/L

The normal range for chloride (Cl⁻) in the blood is typically 95-105 mEq/L. Chloride is an essential electrolyte that helps maintain the body’s fluid and acid-base balance. It works in conjunction with sodium and other ions to regulate osmotic pressure and maintain electrical neutrality in cells. Abnormal levels of chloride can be indicative of a variety of conditions, such as dehydration, kidney disease, or respiratory disorders.

Why are the other options wrong?

A) 135-145 mEq/L:

This range corresponds to the normal range for sodium (Na⁺), not chloride. Sodium plays a significant role in regulating fluid balance and osmotic pressure, but it is not the correct value for chloride.

B) 3.5-5.0 mEq/L:

This range corresponds to potassium (K⁺), not chloride. Potassium is critical for maintaining electrical gradients across cell membranes and muscle function, but it is not related to chloride's normal range.

D) 8.5-10.5 mg/dL:

This range is for calcium (Ca²⁺), not chloride. Calcium plays a key role in bone health, muscle contractions, and nerve transmission, but does not reflect the normal levels of chloride.

Summary:

The correct normal range for chloride (Cl⁻) is 95-105 mEq/L. The other ranges provided (sodium, potassium, calcium) correspond to different electrolytes involved in various physiological processes but are not related to chloride's normal value.

Correct Answer: c. Has violated confidentiality laws and can be held liable.

Explanation

The nurse has violated confidentiality laws because, even though the patient’s name was not used, details about the case (crime-related gunshot wound, emergency department) could allow others to identify the patient. HIPAA and professional nursing standards prohibit sharing any patient-related information on social media, as it compromises confidentiality and trust in healthcare. The nurse could face disciplinary action, termination, or legal consequences.

Explanation of the Incorrect Options:

a. Has not violated confidentiality laws because he did not use the patient’s name.

 Confidentiality is about protecting all identifiable information, not just names. Even without a name, sharing specific case details can lead to patient identification.

b. Cannot be held liable for violating confidentiality laws because he was not the primary nurse for the patient.

HIPAA applies to all healthcare workers, not just the primary nurse. If any staff member gains access to patient information and shares it inappropriately, they are liable.

d. Cannot be held liable because postings on a social media site are excluded from confidentiality laws.

Social media posts are not exempt from HIPAA regulations. Sharing patient information in any form—verbal, written, or online—is a violation.

Summary:

The nurse violated confidentiality laws by posting patient-related information on social media, even without using the patient’s name. Any identifiable patient details must be kept private. Nurses must follow HIPAA regulations and professional ethical standards to protect patient confidentiality.

The correct answer is:  D) Denial

Explanation

Denial is a defense mechanism in which a person refuses to accept reality or facts, often as a way to cope with painful emotions. In this case, the client is rejecting the medical prognosis and holding onto the belief that their partner will recover, despite evidence to the contrary. This is a common reaction when facing the impending loss of a loved one.

Explanation of Why the Other Options Are Incorrect:

Displacement

Displacement occurs when a person redirects emotions from the original source to a safer or less threatening object or person. Example: A client who is angry about their partner’s illness might yell at a nurse or family member instead of expressing anger toward the situation itself. This does not match the scenario because the client is not redirecting emotions but rather refusing to accept reality.

Splitting

Splitting is when a person sees things in extremes (all good or all bad) and cannot integrate positive and negative aspects of a situation or person. Example: A client might say, "This doctor is amazing, but the other one is completely incompetent," without recognizing any middle ground. The scenario does not suggest extreme thinking about the doctors or treatment, so splitting is not applicable.

Repression

Repression is an unconscious mechanism in which a person blocks distressing thoughts or memories from awareness. Example: A person who was abused as a child may have no conscious memory of the event. In this case, the client acknowledges the diagnosis but rejects the reality of its severity, which aligns more with denial than repression.

Summary:

The client is using denial as a defense mechanism by rejecting the reality of their partner’s prognosis and holding onto hope despite medical evidence. The other options—displacement, splitting, and repression—do not fit the scenario because the client is not redirecting emotions, thinking in extremes, or blocking memories.

The correct answer is: "Speak to the client calmly, giving simple directions."

Explanation:

When managing an agitated client in a mental health setting, the priority is to use the least restrictive intervention first. Calm verbal de-escalation helps to prevent further escalation and allows the client to regain self-control without the need for more restrictive measures. Speaking calmly and giving simple directions can help redirect the client’s behavior in a non-threatening way. The least restrictive to most restrictive approach follows this order:

Verbal interventions (e.g., calm communication, redirection)

Offering PRN medication (if needed and if the client is receptive)

Seclusion (if the client is a danger to self or others and verbal techniques fail)

Restraints (only as a last resort when there is an immediate safety risk)

Why the Other Options Are Incorrect:

"Offer the client a PRN antianxiety medication."

PRN medication may be helpful if the client is receptive, but it is not the first action. The nurse should attempt verbal de-escalation before offering medication.

"Escort the client to an unlocked seclusion room."

Seclusion is more restrictive than verbal de-escalation. It should only be used if verbal interventions fail and the client poses a threat to themselves or others.

"Call for assistance to place the client in restraints."

Restraints should be the last resort and used only if the client poses an immediate danger to themselves or others. Since the client is shouting but has not yet become physically violent, restraints are not appropriate at this stage.

Summary:

The first action should be to speak to the client calmly and provide simple directions to de-escalate the situation. If the client remains agitated or becomes violent, other interventions, such as medication, seclusion, or restraints, may be considered in accordance with the least restrictive means principle.

Correct Answer: D) Persistent worry about losing a parent or caregiver

Explanation 

Persistent worry about losing a parent or caregiver is a hallmark symptom of separation anxiety disorder in children. Children with separation anxiety disorder often have intense fears and worries about the safety of their parents or caregivers when they are not around. They may have thoughts like "What if something happens to my mom or dad?" This fear can make them reluctant to go to school, participate in social activities, or be away from their caregivers, even for short periods of time.

Why the Other Options Are Incorrect:

A) Excessive interest in social activities:

Children with separation anxiety typically avoid social situations, especially if these involve being apart from their caregivers. They may isolate themselves and show little interest in social activities because of the fear of separation, which makes this option incorrect.

B) Desire to spend more time alone:

While some children with separation anxiety might show reluctance to interact socially, it is not about a desire to spend more time alone. The anxiety is about being separated from their caregiver, not about preferring solitude. In fact, many children with separation anxiety may seek to be with their caregivers or other trusted adults more often.

C) Increased appetite:

Children with separation anxiety are more likely to experience changes in behavior such as refusal to eat or upset stomachs, particularly when anxious about separation. Increased appetite is not a typical symptom associated with separation anxiety disorder.

Summary:

Persistent worry about losing a parent or caregiver is a key symptom of separation anxiety disorder. This intense worry can manifest in various ways, including reluctance to go to school or social events, nightmares, or physical complaints (e.g., stomachaches) related to the separation. Children with separation anxiety struggle with being away from their caregivers and often need reassurance to manage their fears.