ATI RN
ATI Mental Health Proctored Exam 2023 Quizlet
1. A distraught, single, first-time mother cries and asks a nurse, 'How can I go to work if I can't afford childcare?' What is the nurse's initial action in assisting the client with the problem-solving process?
- A. Determine the risks and benefits for each alternative.
- B. Formulate goals for resolution of the problem.
- C. Evaluate the outcome of the implemented alternative.
- D. Assess the facts of the situation.
Correct answer: D
Rationale: In this scenario, the nurse's initial step should be to assess the facts of the situation. By gathering accurate information about the client's circumstances, the nurse can better understand the problem and make informed decisions moving forward. This foundational assessment is crucial before proceeding to formulate goals, evaluate outcomes, or consider risks and benefits. Options A, B, and C involve steps that should follow the initial assessment of the situation, making them less suitable as the initial action in this context.
2. What is the correct action when a patient reports cramping during enema administration?
- A. Lower the height of the solution container
- B. Increase the flow of the enema solution
- C. Stop the procedure and remove the tubing
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: The correct action to take when a patient reports cramping during enema administration is to lower the height of the solution container. Lowering the height reduces the pressure and speed of the solution entering the rectum, alleviating cramping. Increasing the flow of the enema solution (Choice B) can worsen the discomfort. Stopping the procedure and removing the tubing (Choice C) is not necessary unless there are severe complications. Continuing the enema at a slower rate (Choice D) may not effectively address the immediate cramping issue and could still cause discomfort to the patient.
3. The client is recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?
- A. The client lies flat in the supine position for 12 hours
- B. The client continues oral fluids restriction while on bed rest
- C. The client’s family changed the dressing on return to the room
- D. The family activates the patient-controlled analgesia pump
Correct answer: A
Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy helps prevent bleeding, which is crucial for the client's recovery. This position aids in applying pressure to the biopsy site, reducing the risk of bleeding and ensuring optimal healing. Choices B, C, and D do not directly relate to compliance with client teaching after a renal biopsy. Continuing oral fluids restriction, changing the dressing, or activating a patient-controlled analgesia pump are not specific instructions aimed at promoting recovery and preventing complications post renal biopsy.
4. The nurse notes that a child has lost 3.6 kg (8 lb) after 4 days of hospitalization for acute glomerulonephritis. What is the most likely cause of this weight loss?
- A. Poor appetite
- B. Reduction of edema
- C. Restriction to bed rest
- D. Increased potassium intake
Correct answer: B
Rationale: The weight loss is most likely due to the reduction of edema, as glomerulonephritis often causes fluid retention that resolves with treatment, leading to significant weight loss.
5. A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?
- A. Check for gastric residual.
- B. Apply low intermittent suction.
- C. Increase the rate of the feeding.
- D. Request a higher-fat formula.
Correct answer: A
Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.
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