a nurse is caring for a client who has vision loss which of the following actions should the nurse take a nurse is caring for a client who has vision loss which of the following actions should the nurse take
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ATI RN

ATI Exit Exam 2023 Quizlet

1. A client with vision loss is being cared for by a nurse. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to keep objects in the client's room in the same place. This helps individuals with vision loss navigate their environment more easily by creating a familiar and consistent layout. Choice B, ensuring high-wattage lighting, may not be suitable for all clients with vision loss and can cause discomfort or glare. Approaching the client from the side (Choice C) can startle them and is not recommended. Touching the client (Choice D) without warning may cause anxiety or distress, so it's important to announce presence verbally.

2. During a mental health assessment on an adult client, which client action would demonstrate the highest achievement in terms of mental health according to Maslow's hierarchy of needs?

Correct answer: C

Rationale: In Maslow's hierarchy of needs, self-actualization is the highest level. Possessing a feeling of self-fulfillment and realizing full potential reflects self-actualization. This level represents achieving personal growth, self-improvement, and reaching one's full potential, indicating optimal mental health. Choices A, B, and D represent lower levels of needs according to Maslow's hierarchy. Maintaining a long-term relationship indicates belongingness and love needs, achieving self-confidence pertains to esteem needs, and developing a sense of purpose relates to self-esteem and self-actualization needs, but they are not at the pinnacle of self-actualization as in choice C.

3. Discharge plans of diabetic clients include injection site rotation. You should emphasize that the space between sites should be:

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. Which action represents a primary prevention strategy?

Correct answer: B

Rationale: Administering vaccines is a primary prevention strategy because it aims to prevent diseases before they occur by providing immunity against specific pathogens. Educating children on handwashing is important for preventing infections but falls under health promotion rather than primary prevention. Screening for early signs of disease and providing treatment for acute illnesses are considered secondary and tertiary prevention strategies, respectively, as they aim to detect and treat diseases that have already developed to prevent further complications.

5. When caring for a client who is to have a line placed for hemodynamic monitoring, which statement by the newly licensed nurse indicates effectiveness of the teaching?

Correct answer: D: A chest x-ray is needed to verify placement after the procedure.

Rationale: After a line is placed for hemodynamic monitoring, it is crucial to confirm its correct placement. The definitive way to verify the placement is through a chest x-ray. This ensures that the line is appropriately positioned without complications. Options A, B, and C do not address the essential step of confirming the line's placement, making them incorrect choices.

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