ATI RN
ATI Mental Health
1. A client is experiencing a panic attack. Which action should the nurse take first?
- A. Remain with the client and offer reassurance.
- B. Administer an anti-anxiety medication as prescribed.
- C. Encourage the client to engage in physical activity.
- D. Encourage the client to breathe deeply and slowly.
Correct answer: A
Rationale: During a panic attack, the immediate priority for the nurse is to provide support and reassurance to the client. Remaining with the client helps establish a sense of safety and trust, which can help calm the client during an episode of panic. Administering medication, encouraging physical activity, and deep breathing techniques are beneficial interventions, but offering reassurance and support should be the initial step to address the immediate emotional distress and anxiety experienced by the client.
2. Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture?
- A. The client will complete activities of daily living.
- B. The client will maintain safety.
- C. The client will remain oriented.
- D. The client will understand communication.
Correct answer: B
Rationale: The correct answer is B: 'The client will maintain safety.' For a client with delirium, especially in the context of acute confusion post-surgery, safety is the top priority. Delirium can lead to disorientation, impaired decision-making, and increased risk of falls or accidents. Ensuring the client's safety by implementing measures to prevent harm is crucial. Choices A, C, and D are important but not the priority in this scenario. Completing activities of daily living, remaining oriented, and understanding communication are relevant goals but come after ensuring the client's safety in the presence of delirium and acute confusion.
3. A nurse is providing discharge teaching to a client with type 2 diabetes mellitus. Which of the following resources should the nurse provide?
- A. Personal blogs about managing diabetes medications.
- B. Food label recommendations from the Institute of Medicine.
- C. Diabetes medication information from the Physicians' Desk Reference.
- D. Food exchange lists for meal planning from the American Diabetes Association.
Correct answer: D
Rationale: The correct answer is D. Food exchange lists are valuable resources for individuals with diabetes as they provide structured meal planning guidance. This helps individuals manage their diabetes effectively by controlling their carbohydrate intake. Choices A, B, and C are incorrect because personal blogs may not provide reliable and evidence-based information, food label recommendations from the Institute of Medicine may not be specific for diabetes meal planning, and diabetes medication information from the Physicians' Desk Reference is not directly related to meal planning for diabetes management.
4. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?
- A. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed.
- B. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur.
- C. Discourage parent presence during procedures on infants and toddlers.
- D. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.
Correct answer: D
Rationale: Using simple diagrams helps school-age children understand what to expect in a procedure, catering to their developmental level and reducing anxiety. Informing toddlers too early can increase anxiety, and parents' presence is generally comforting, not discouraging.
5. A client has experienced a pontine stroke which has resulted in severe hemiparesis. What priority assessment should the nurse perform prior to allowing the client to eat or drink from the food tray?
- A. Evaluate the client's gag reflex.
- B. Assess the client's bowel sounds.
- C. Check the client's pupil reaction.
- D. Monitor the client's heart rate.
Correct answer: A
Rationale: The correct answer is to evaluate the client's gag reflex. When a client has experienced a stroke resulting in severe hemiparesis, assessing the gag reflex is crucial before allowing them to eat or drink. This assessment helps prevent aspiration, a serious complication that can occur due to impaired swallowing ability. Assessing bowel sounds (Choice B), pupil reaction (Choice C), or heart rate (Choice D) are important assessments but are not the priority in this situation where the risk of aspiration is higher.
Similar Questions
Access More Features
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 90 days access @ $149.99