a nurse is assessing a client who has schizophrenia and experiences auditory hallucinations the client states its hard not to listen to the voices whi
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ATI RN

ATI Exit Exam 2023 Quizlet

1. When a client with schizophrenia who experiences auditory hallucinations says, 'It's hard not to listen to the voices,' which question should the nurse ask?

Correct answer: D

Rationale: The correct question for the nurse to ask the client who experiences auditory hallucinations and finds it hard not to listen to the voices is, 'What helps you ignore what you are hearing?' This question focuses on promoting coping strategies and therapeutic communication, encouraging the client to share what techniques or interventions have been effective for managing the auditory hallucinations. Choice A is incorrect because it assumes the client does not understand that the voices are not real, which may not be the case. Choice B delves into the reasons behind the voices, which may not be immediately helpful in managing the current situation. Choice C suggests a physical solution of going to a private place, which may not address the underlying issue of coping with the voices.

2. 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.

3. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?

Correct answer: D

Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.

4. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

5. What is the appropriate intervention for a patient with hypertension refusing medication?

Correct answer: A

Rationale: The correct answer is A: Educate the patient on the importance of medication. Providing education to the patient is crucial in promoting understanding of the condition and the necessity of medication. By enhancing the patient's knowledge, healthcare providers can empower them to make informed decisions regarding their health. Choice B, respecting the patient's decision, may not be appropriate in this scenario as untreated hypertension can lead to serious complications. Choice C, informing the healthcare provider, is important but should be done after attempting to educate the patient. Choice D, exploring alternative treatment options, may be considered if the patient has concerns or side effects related to the medication, but initially, educating the patient about the importance of medication is key.

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