a nurse is caring for a client who has experienced intimate partner violence what is the nurses priority
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse is caring for a client who has experienced intimate partner violence. What is the nurse's priority?

Correct answer: A

Rationale: The correct answer is A: 'Develop a safety plan with the client.' When caring for a client who has experienced intimate partner violence, the nurse's priority is to ensure the client's safety. Developing a safety plan is essential to address the immediate safety concerns and provide support to the client. Referring the client to a community support group, as in option B, may be beneficial but is not the immediate priority. While determining if the client has any injuries, as in option C, is important for assessing physical well-being, the priority is to address safety concerns first. Contacting the client's family about the incident, as in option D, is not appropriate without the client's consent and may further endanger the client.

2. A client with osteoporosis needs to increase calcium intake. Which of the following foods should be recommended by the nurse?

Correct answer: B

Rationale: The correct answer is B: Broccoli. Broccoli is rich in calcium and is a suitable food to recommend to clients with osteoporosis to increase their calcium intake. Carrots, chicken, and bananas are not as high in calcium content compared to broccoli and therefore not the most appropriate choices for increasing calcium intake in clients with osteoporosis.

3. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Tachycardia. Tachycardia is a common sign of dehydration because the body tries to compensate for the reduced fluid volume by increasing the heart rate. Bradycardia (choice A) is not typically seen in dehydration as the body tries to maintain perfusion. Increased skin turgor (choice B) is actually a sign of dehydration, but tachycardia is a more specific finding. A bounding pulse (choice D) is associated with conditions like hyperthyroidism or aortic regurgitation, not dehydration.

4. A client on glucocorticoid therapy is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Taking a calcium supplement daily is crucial for clients on glucocorticoid therapy to prevent osteoporosis, a common side effect of long-term use. Choice A is unrelated to glucocorticoid therapy. Choice C, limiting potassium intake, is not necessary for clients on glucocorticoids. Choice D, taking medication consistently in the evening, is important but does not specifically address the side effects of glucocorticoid therapy.

5. A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?

Correct answer: D

Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.

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