a nurse is caring for a client who is experiencing alcohol withdrawal which symptom should the nurse identify as a priority to address a nurse is caring for a client who is experiencing alcohol withdrawal which symptom should the nurse identify as a priority to address
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?

Correct answer: C

Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.

2. A patient with a history of hypertension presents with a severe headache, confusion, and visual disturbances. His blood pressure is 220/120 mm Hg. Which of the following is the most likely diagnosis?

Correct answer: C

Rationale: A patient with a history of hypertension presenting with a severe headache, confusion, and visual disturbances, along with a blood pressure of 220/120 mm Hg, likely has a hypertensive emergency. In this situation, the severely elevated blood pressure can lead to end-organ damage, causing symptoms such as headache and confusion. Migraine and tension headaches are not associated with such high blood pressure levels. Cluster headaches typically do not present with visual disturbances and confusion in the setting of severe hypertension.

3. A client is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?

Correct answer: A

Rationale: The therapeutic effect of lisinopril, an ACE inhibitor, is indicated by a decrease in blood pressure. Lisinopril works by relaxing blood vessels, leading to a reduction in blood pressure. Monitoring and achieving a decrease in blood pressure is a key outcome when managing hypertension with lisinopril. Choices B, C, and D are incorrect because lisinopril is not intended to increase HDL cholesterol, prevent bipolar manic episodes, or improve sexual function. Therefore, the correct outcome indicating the therapeutic effect of lisinopril is a decrease in blood pressure.

4. Under which category does a violation of the nurse practice act fall?

Correct answer: B

Rationale: A violation of the nurse practice act falls under the category of a felony. Felony offenses are the most serious and can include acts like homicide and violations of professional practice regulations. Choices A, C, and D are incorrect because violations of the nurse practice act are considered more severe than misdemeanors, torts, or related to juvenile cases.

5. A patient with Crohn’s disease is experiencing diarrhea. Which dietary recommendation is appropriate?

Correct answer: B

Rationale: A low-residue diet is the appropriate dietary recommendation for a patient with Crohn’s disease experiencing diarrhea. This diet helps reduce bowel movements and manage diarrhea by limiting the intake of foods that are harder to digest. High-fiber diets (Choice A) may worsen diarrhea due to increased bulk in the stool. High-fat diets (Choice C) can be harder to digest and may exacerbate symptoms. High-protein diets (Choice D) are not specifically recommended for managing diarrhea in Crohn’s disease.

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