a nurse is assessing a client who is receiving a blood transfusion which of the following findings indicates the client might be experiencing an acute a nurse is assessing a client who is receiving a blood transfusion which of the following findings indicates the client might be experiencing an acute
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing an acute hemolytic reaction?

Correct answer: C

Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.

2. Which of the following is a recommendation for avoiding charges of negligence and false imprisonment for confused clients?

Correct answer: A

Rationale: The correct answer is A: 'Carefully assess and document client status.' When dealing with confused clients, it is crucial to assess their status carefully and document it accurately. This helps in avoiding charges of negligence and false imprisonment by ensuring that the client's condition is well-documented and appropriate care is provided. Choice B is incorrect because it focuses on computer security rather than client care. Choice C is incorrect because it emphasizes detailed notes for accuracy but does not specifically address the confusion of clients. Choice D is incorrect as it mentions discussing safety needs but does not directly relate to avoiding charges of negligence and false imprisonment for confused clients.

3. A client has a new prescription for Clonidine to assist with maintenance of abstinence from opioids. The nurse should instruct the client to monitor for which of the following adverse effects?

Correct answer: B

Rationale: Dry mouth is a common adverse effect associated with clonidine use. Clonidine is known to cause xerostomia (dry mouth) due to its effect on reducing salivary flow. Monitoring for dry mouth is important as it can lead to oral health issues and discomfort for the client. Diarrhea, insomnia, and hypertension are not typically associated with clonidine use, making them less likely adverse effects to monitor for in this scenario.

4. A nurse is assessing a client who has been diagnosed with persistent depressive disorder (dysthymia). Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct finding the nurse should expect in a client diagnosed with persistent depressive disorder (dysthymia) is a lack of interest in activities. This disorder is characterized by a chronic depressive mood lasting for at least two years, alongside symptoms such as changes in appetite, fatigue, low self-esteem, and difficulty concentrating. Clients with dysthymia do not typically experience hypomania, periods of elevated mood, or feelings of detachment from one's body, which are more commonly associated with other mood disorders. Therefore, options A, B, and D are incorrect findings for a client with persistent depressive disorder.

5. Loss of smell results in a condition that limits capacity to detect the flavor of food and beverages called:

Correct answer: C

Rationale: Anosmia is the loss of the sense of smell, which significantly impacts the ability to detect flavors in food and beverages.

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