ATI RN
ATI Mental Health
1. During an assessment, a nurse observes a client showing signs of moderate anxiety. Which symptom is not typically associated with moderate anxiety?
- A. Fidgeting
- B. Laughing inappropriately
- C. Palpitations
- D. Nail biting
Correct answer: C
Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.
2. Which nonpharmacological intervention does not help reduce edema?
- A. Heat therapy
- B. Passive range of motion (PROM)
- C. Elevation of the extremity
- D. Cold therapy
Correct answer: A
Rationale: The correct answer is A: Heat therapy. Heat therapy can vasodilate blood vessels, increasing blood flow to the area and potentially exacerbating edema. Passive range of motion (PROM), elevation of the extremity, and cold therapy are all beneficial interventions for reducing edema. PROM helps with circulation, elevation assists in reducing fluid accumulation, and cold therapy can help constrict blood vessels and decrease swelling.
3. The unique clinical presentation of a 3-month-old infant in the emergency department leads the care team to suspect botulism. Which assessment question posed to the parents is likely to be most useful in the differential diagnosis?
- A. Has your child received all recommended vaccinations?
- B. Has your child been feeding poorly or showing signs of constipation?
- C. Has your child been exposed to any sick individuals?
- D. Has your child been displaying signs of respiratory distress?
Correct answer: B
Rationale: The correct answer is B. Poor feeding and constipation are common early symptoms of infant botulism, which is caused by a neurotoxin that impairs muscle function. Option A is unrelated to the presentation of botulism. Option C does not directly relate to the symptoms of botulism. Option D is more indicative of respiratory issues rather than the constellation of symptoms seen in botulism.
4. From a unit perspective, disruptive and violent patient behavior may be distracting to patients and staff. As the nurse manager, you are concerned about: (EXCEPT)
- A. Patient and staff safety.
- B. Team tension.
- C. Fear of disappointment.
- D. Stress levels.
Correct answer: C
Rationale: Disruptive and violent patient behavior can indeed pose challenges on a unit. Concerns as a nurse manager would revolve around patient and staff safety (Choice A) due to the risk of harm, team tension (Choice B) arising from managing such situations, and stress levels (Choice D) of both patients and staff. Fear of disappointment (Choice C) is not a typical concern in this scenario and does not directly relate to the immediate impact of disruptive and violent patient behavior.
5. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?
- A. Hypertension, bradycardia, and oliguria
- B. Bradycardia, hypertension, and peripheral edema
- C. Tachypnea, cool skin, and confusion
- D. Tachycardia, hypotension, and decreased urine output
Correct answer: D
Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.
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