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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?
- A. Encourage them to initiate daily rituals.
- B. Reinforce the reality of their financial situation.
- C. Direct them to drink a glass of red wine at bedtime.
- D. Teach them to limit sugar and caffeine intake.
Correct answer: D
Rationale: Teaching the individual to limit sugar and caffeine intake is an appropriate intervention to reduce anxiety and improve sleep quality. Sugar and caffeine can exacerbate anxiety symptoms and disrupt sleep patterns. By reducing their intake, the individual may experience a decrease in anxiety levels and better sleep. Encouraging daily rituals, reinforcing financial realities, or suggesting alcohol consumption before bed are not evidence-based strategies for managing anxiety and sleeplessness.
2. The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?
- A. Increase your intake of high-calcium foods.
- B. Limit your intake of vitamin D-rich foods.
- C. Avoid foods high in phosphorus.
- D. Increase your intake of high-sodium foods.
Correct answer: A
Rationale: Increasing the intake of high-calcium foods is essential for improving bone density and managing osteoporosis. Calcium is a key mineral necessary for bone health, and individuals with osteoporosis often need higher levels of calcium to help strengthen their bones and prevent further bone loss. Therefore, advising the client to increase their intake of high-calcium foods is the most appropriate dietary modification to support their bone health.
3. A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct answer: D
Rationale: Seizures in a client with suspected meningitis indicate increased intracranial pressure or other complications requiring immediate intervention. Seizures can lead to further neurological damage and need prompt management to prevent adverse outcomes. Therefore, addressing seizures promptly is crucial in the care of a client with suspected meningitis.
4. A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula for hemodialysis. Which finding should the nurse report to the healthcare provider immediately?
- A. No bruit or thrill over the AV fistula.
- B. Redness at the site of the AV fistula.
- C. Client's complaint of pain at the AV fistula site.
- D. Swelling of the hand on the side of the AV fistula.
Correct answer: A
Rationale: In a client with a chronic kidney disease who has an arteriovenous (AV) fistula for hemodialysis, the absence of a bruit (a humming sound) or thrill (vibratory sensation) over the AV fistula indicates a potential occlusion. This finding suggests inadequate blood flow through the AV fistula, which is a critical issue requiring immediate intervention to prevent complications such as thrombosis or clot formation. Reporting this absence of bruit or thrill promptly to the healthcare provider is essential to ensure timely assessment and management to maintain vascular access for hemodialysis.
5. A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?
- A. Encourage the client to remove the gun from her possession.
- B. Notify the client's healthcare provider of the availability of the weapon.
- C. Contact a person of the client's choosing to remove the weapon from the home.
- D. Call the local police department and have the weapon removed from the home.
Correct answer: C
Rationale: In this scenario, it is crucial to maintain the client's confidentiality while ensuring her safety. Contacting a person chosen by the client to remove the weapon from her home is the best course of action. This approach respects the client's autonomy and helps reduce the risk of harm without involving external authorities unnecessarily.
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