a nurse is planning care for a client who has alzheimers disease and demonstrates confusion and wandering behavior which of the following should the n
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

2. A nurse is caring for a client who has schizophrenia. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: The correct answer is B: Inability to identify common objects. Clients with schizophrenia often experience cognitive deficits, such as difficulty in identifying common objects. This can be attributed to impairments in perception and cognition. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head injuries or metabolic disturbances. Preoccupation with somatic disturbances is commonly seen in somatic symptom disorders, not schizophrenia. Poor problem-solving ability is a characteristic of conditions affecting executive functioning like dementia, rather than schizophrenia.

3. What is the first intervention for a patient experiencing anaphylactic shock?

Correct answer: A

Rationale: The correct answer is to administer epinephrine as the first intervention for a patient experiencing anaphylactic shock. Epinephrine is crucial in reversing the allergic reaction and restoring cardiovascular stability. Corticosteroids (Choice B) are not the first-line treatment for anaphylactic shock but may be used as an adjunct therapy. Antihistamines (Choice C) can help relieve itching and hives but are not as effective as epinephrine in treating the systemic effects of anaphylaxis. Oxygen (Choice D) may be necessary to support breathing in severe cases of anaphylaxis, but administering epinephrine takes precedence in the management of anaphylactic shock.

4. What is the priority nursing action for a patient with confusion post-surgery?

Correct answer: A

Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.

5. A nurse is planning care for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse implement to prevent respiratory complications?

Correct answer: C

Rationale: The correct answer is C. Encouraging the client to use an incentive spirometer every hour is crucial to prevent respiratory complications postoperatively. Incentive spirometry helps in lung expansion and prevents atelectasis, which is common after abdominal surgery. Choice A, encouraging ambulation, is important for preventing complications but does not directly address respiratory issues. Choice B, deep breathing and coughing every hour, is also beneficial but not as effective in preventing atelectasis as using an incentive spirometer. Choice D, instructing the client to avoid coughing, is incorrect as coughing helps clear secretions and prevent respiratory complications.

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