a client is discussing feelings related to a recent loss with the nurse the nurse remains silent when the client says i dont know how i will go on wha
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Nursing Elites

ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

1. When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?

Correct answer: D

Rationale: In therapeutic communication, silence can offer the client an opportunity to process their emotions and thoughts. By remaining silent, the nurse provides a space for the client to reflect on their own words, facilitating deeper exploration and understanding of their feelings.

2. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

Correct answer: B

Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.

3. A patient is being cared for after bariatric surgery, and the healthcare provider is assessing for hemorrhage. What is a sign of hemorrhage?

Correct answer: B

Rationale: Frank red bleeding from the surgical site is a significant sign of hemorrhage that warrants immediate attention. It indicates active bleeding that needs to be addressed promptly to prevent further complications.

4. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?

Correct answer: D

Rationale: Ventricular fibrillation is a life-threatening arrhythmia characterized by chaotic, asynchronous contractions of the ventricles, resulting in ineffective cardiac output. This leads to the absence of a palpable pulse. Nurses should be prepared to initiate immediate interventions such as defibrillation to restore normal cardiac rhythm in a client experiencing ventricular fibrillation.

5. When working with a client who has chronic constipation, what should be included in client teaching to promote normal bowel function?

Correct answer: C

Rationale: Consuming high-residue, high-fiber foods is essential in promoting normal bowel function and preventing constipation. These foods help add bulk to the stool, making it easier to pass and preventing constipation. Glycerin suppositories may provide short-term relief but are not a long-term solution for chronic constipation. Physical activity actually helps promote bowel peristalsis, so limiting it would not be beneficial. Delaying defecation can lead to stool hardening and worsening constipation.

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