a nurse is assessing a client with a history of seizures which assessment finding requires immediate intervention
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam

1. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.

2. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Correct answer: D

Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.

3. A client with chronic obstructive pulmonary disease (COPD) is being taught by a healthcare provider. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. While exercise is important for clients with COPD, daily exercise may be too strenuous. Clients should be encouraged to exercise regularly but should be advised to avoid overexertion. Statements A, B, and D demonstrate appropriate understanding and management of COPD symptoms.

4. A healthcare professional wishes to provide client-centered care in all interactions. Which action by the healthcare professional best demonstrates this concept?

Correct answer: A

Rationale: Client-centered care focuses on individualizing care to meet the client's unique needs, preferences, and values. Assessing for cultural influences affecting healthcare allows the healthcare professional to provide culturally sensitive and competent care, respecting the client's beliefs and practices. It promotes effective communication, understanding, and collaboration, essential components of client-centered care.

5. A client with a pleural effusion is being assessed by a nurse. Which clinical manifestation does the nurse expect to find?

Correct answer: A

Rationale: In a client with pleural effusion, decreased breath sounds on the affected side are common due to the presence of fluid in the pleural space. Hyperresonance is not expected; dullness on percussion is more likely. Tactile fremitus is typically decreased, not increased, in pleural effusion cases. Tracheal deviation away from the affected side, not toward it, can be seen with large effusions.

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