a nurse is planning care for a client who has a prescription for mechanical restraints which of the following interventions should the nurse include i

ATI LPN

ATI PN Comprehensive Predictor

1. A healthcare professional is planning care for a client who has a prescription for mechanical restraints. Which of the following interventions should the healthcare professional include in the plan?

A. Document the client's status every 60 minutes.
B. Provide a staff member to stay with the client continuously.
C. Measure vital signs every 4 hours.
D. Obtain a prescription for the restraints every 8 hours.

Correct answer: B

Rationale: When a client has a prescription for mechanical restraints, it is essential to provide continuous monitoring for their safety and to observe any behavioral changes. Having a staff member stay with the client continuously allows for immediate intervention if needed. Documenting the client's status every 60 minutes (Choice A) may not provide real-time monitoring, which is crucial in this situation. While measuring vital signs every 4 hours (Choice C) is important, continuous observation takes precedence in this scenario. Obtaining a prescription for the restraints every 8 hours (Choice D) is not a necessary intervention once the initial prescription is in place.

2. How should a healthcare provider assess and manage a patient with a potential myocardial infarction (MI)?

A. Assess symptoms, monitor vital signs, order ECG
B. Administer medications and monitor for pain
C. Administer thrombolytics and oxygen therapy
D. Educate patient on lifestyle changes

Correct answer: A

Rationale: Correct Answer: A. When assessing a patient with a potential myocardial infarction, it is crucial to assess symptoms, monitor vital signs like blood pressure and heart rate, and order an electrocardiogram (ECG) to evaluate for cardiac abnormalities. Choice B is incorrect because administering medications should be based on the findings of the assessment and diagnostic tests, not administered indiscriminately. Choice C is incorrect because the administration of thrombolytics and oxygen therapy should be based on specific criteria and should be done in a controlled setting. Choice D is incorrect as educating the patient on lifestyle changes is important for prevention but is not the immediate priority when managing a potential myocardial infarction.

3. How should a healthcare professional assess a patient with chest pain?

A. Assess the severity of pain and monitor ECG
B. Administer nitroglycerin and provide oxygen
C. Administer aspirin and provide pain relief
D. Monitor for nausea and administer IV fluids

Correct answer: A

Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.

4. What are the key differences between hypoglycemia and hyperglycemia?

A. Hypoglycemia: Sweating, trembling; Hyperglycemia: Frequent urination, thirst
B. Hypoglycemia: Increased thirst; Hyperglycemia: Sweating, confusion
C. Hypoglycemia: Increased appetite; Hyperglycemia: Blurred vision
D. Hypoglycemia: Dizziness; Hyperglycemia: Low blood pressure

Correct answer: A

Rationale: Hypoglycemia typically presents with sweating and trembling, while hyperglycemia is characterized by frequent urination and thirst. Therefore, the correct key differences between hypoglycemia and hyperglycemia are that hypoglycemia includes symptoms like sweating and trembling, while hyperglycemia involves symptoms such as frequent urination and thirst. Choices B, C, and D are incorrect because they do not accurately represent the characteristic symptoms of hypoglycemia and hyperglycemia, as stated in the question.

5. A client has undergone a myelogram, and a nurse is providing post-procedure care. Which action should be included in the nursing care plan?

A. Encourage ambulation after the procedure
B. Maintain the prone position for 12 hours
C. Evaluate the client's distal pulses on the affected side
D. Encourage oral fluid intake

Correct answer: C

Rationale: The correct action to include in the nursing care plan for a client post-myelogram is to evaluate the client's distal pulses on the affected side. This is crucial to assess circulation and detect any potential complications such as impaired blood flow or vascular issues. Encouraging ambulation after the procedure (Choice A) is not typically recommended immediately post-myelogram, as the client may need to rest. Maintaining the prone position for 12 hours (Choice B) is an outdated practice and is no longer part of standard care post-myelogram. Encouraging oral fluid intake (Choice D) is generally beneficial for hydration but is not a specific priority related to post-myelogram care.