ATI RN
Leadership ATI Proctored
1. A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. "I can concentrate best in the morning."
- B. "It is difficult to read the instructions because my glasses are at home."
- C. "I'm wondering why I need to learn this."
- D. "You will have to talk to my partner about this."
Correct answer: D
Rationale: The correct answer is D, "You will have to talk to my partner about this." This response indicates that the client is willing to involve their partner in the learning process, showing readiness to take responsibility and engage in the education. Choices A, B, and C demonstrate potential barriers to learning: A indicates a preference for learning time but does not show active involvement, B focuses on external factors hindering learning, and C reflects a lack of understanding or motivation for the learning.
2. The client on amiodarone develops pulmonary fibrosis. What action should the nurse take?
- A. Notify the healthcare provider immediately.
- B. Continue the medication and monitor lung function.
- C. Discontinue the medication and start oxygen therapy.
- D. Reduce the dose and monitor respiratory status.
Correct answer: A
Rationale: When a client on amiodarone develops pulmonary fibrosis, a serious side effect, the immediate action the nurse should take is to notify the healthcare provider. This is crucial because pulmonary fibrosis can lead to severe respiratory compromise and requires prompt evaluation and management by the healthcare provider. Continuing the medication (choice B) can worsen the condition, and delaying action by reducing the dose and monitoring respiratory status (choice D) may not be appropriate given the seriousness of pulmonary fibrosis. Discontinuing the medication and starting oxygen therapy (choice C) may be necessary, but the priority is to notify the healthcare provider first for further assessment and guidance.
3. When assessing a client diagnosed with post-traumatic stress disorder (PTSD), which finding should the nurse expect?
- A. Hypervigilance
- B. Insomnia
- C. Flashbacks
- D. Suicidal ideation
Correct answer: A
Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.
4. A patient with breast cancer is prescribed tamoxifen (Nolvadex). What important information should the nurse provide during patient education?
- A. Tamoxifen may increase the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots.
- B. Tamoxifen may cause weight gain, so patients should monitor their diet.
- C. Tamoxifen may decrease the risk of osteoporosis, so patients should ensure adequate calcium intake.
- D. Tamoxifen may increase the risk of breast cancer, so regular mammograms are essential.
Correct answer: A
Rationale: The correct answer is A. Tamoxifen increases the risk of venous thromboembolism, a serious side effect, so patients should be educated about the signs and symptoms of blood clots. This information is crucial as early recognition and prompt treatment of blood clots can prevent complications. Choices B, C, and D are incorrect because tamoxifen is not associated with causing weight gain, decreasing the risk of osteoporosis, or increasing the risk of breast cancer. Providing accurate information is essential for patient safety and understanding.
5. A client has a new prescription for Metformin. Which of the following adverse effects of Metformin should the nurse instruct the client to report to the provider?
- A. Somnolence
- B. Constipation
- C. Fluid retention
- D. Weight gain
Correct answer: A
Rationale: The correct answer is 'A: Somnolence.' Somnolence can indicate lactic acidosis, which is manifested by extreme drowsiness, hyperventilation, and muscle pain. It is a rare but very serious adverse effect caused by metformin and should be reported to the provider promptly to prevent further complications.
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