a nurse in a mental health facility receives a change of shift report on four clients which of the following clients should the nurse plan to assess f a nurse in a mental health facility receives a change of shift report on four clients which of the following clients should the nurse plan to assess f
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?

Correct answer: A

Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.

2. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify which finding as an indication of effective treatment?

Correct answer: B

Rationale: The correct answer is B. The client reporting feeling less anxious is a positive indication of effective treatment for a pulmonary embolism. This suggests that the client's condition is improving psychologically. Option A is incorrect because increased density in all lung fields on a chest x-ray may indicate unresolved issues related to the embolism. Option C is incorrect as diminished breath sounds bilaterally suggest a complication or worsening of the condition. Option D is incorrect as ABG results within normal range do not necessarily indicate effective treatment for a pulmonary embolism, as other complications may still be present.

3. The nurse is aware that if patients from different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what?

Correct answer: B

Rationale: Ethnocentrism is the belief that one's own culture is superior to others, which can lead to bias and a lack of cultural competence in healthcare.

4. To promote independence, which of these is the best intervention to implement?

Correct answer: D

Rationale: The correct answer is to allow the client to perform the activities of daily living they are able to do. This intervention promotes independence by encouraging clients to maintain their functional abilities. Choice A is incorrect as performing the client's activities of daily living for them does not empower independence. Choice B is irrelevant to promoting independence. Choice C is not actively promoting independence as it involves leaving the client alone without any guidance or support.

5. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

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