a nurse is admitting a client who has been having frequent tonic clonic seizures which of the following actions should the nurse add to the clients pl
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Nursing Elites

ATI RN

ATI Leadership Proctored Exam 2023

1. A client with frequent tonic-clonic seizures is being admitted. What action should the nurse add to the client's plan of care?

Correct answer: D

Rationale: The correct action the nurse should add to the client's plan of care is to have a tongue depressor available at the client's bedside. This is important during a seizure to prevent the client from biting their tongue. Placing the client laterally helps maintain a clear airway and prevents aspiration, making choice C a good practice during seizure activity. Using restraints during a seizure can cause injuries and should be avoided, making choice B incorrect. Wrapping blankets around all four sides of the bed is unnecessary for seizure management and does not contribute to the client's safety during a seizure, making choice A incorrect.

2. A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct answer is C because after a lumbar laminectomy, the adolescent may need assistance with personal hygiene due to limited mobility and pain. Encouraging the guardian to assist with personal hygiene ensures proper care and prevents complications. Choice A is incorrect as limiting visitors may affect the adolescent's emotional well-being and support system. Choice B is incorrect as the adolescent should have autonomy in selecting their food choices as long as they align with their dietary restrictions post-surgery. Choice D is incorrect as the adolescent may need guidance and support in decision-making during the postoperative period.

3. 1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select one that doesn't apply)?

Correct answer: C

Rationale: The correct answer is C: Chest x-ray. While monitoring for complications in a patient with type 2 diabetes, annual tests such as blood pressure measurement, serum creatinine levels, and urine for microalbuminuria are essential. These tests help in assessing kidney function, cardiovascular health, and early signs of kidney damage, which are common complications of diabetes. A chest x-ray is not routinely scheduled annually to monitor for complications related to type 2 diabetes, making it the least applicable option.

4. Which of the following is an example of a primary prevention strategy?

Correct answer: A

Rationale: Administering vaccinations is indeed an example of a primary prevention strategy. Primary prevention aims to prevent the occurrence of a disease or injury before it occurs by targeting the entire population or specific high-risk groups. Vaccinations help prevent the initial development of a disease by enhancing immunity against specific pathogens. Choices B, C, and D are not examples of primary prevention strategies. Performing a surgical procedure (Choice B) is a treatment intervention, not a preventive measure. Teaching healthy lifestyle choices (Choice C) falls under health promotion and education, which is more aligned with secondary prevention. Prescribing medication (Choice D) is typically associated with treatment rather than preventing the initial onset of a disease.

5. Staff are sometimes injured when a patient or visitor becomes agitated. If a staff member reports an injury, the following actions should take place: (EXCEPT)

Correct answer: B

Rationale: When a staff member reports an injury resulting from an agitated patient or visitor, several actions should be taken. These actions include notifying security to ensure safety, notifying the nursing supervisor for appropriate follow-up, and ensuring that the injured staff member has been examined to assess the extent of the injury. Completing an incident report is not the correct action to exclude because documenting the incident is crucial for legal and healthcare purposes. Incident reports provide a detailed account of what occurred, which is essential for investigations, insurance claims, and improving safety protocols. Therefore, all other options are necessary steps to take when a staff member reports an injury, making completing an incident report the correct answer for exclusion.

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