a nurse is planning care for a client who is experiencing acute mania what intervention should the nurse include
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

2. A client has thrombocytopenia. What action should the nurse include?

Correct answer: C

Rationale: The correct action for the nurse when caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is characterized by a low platelet count, leading to increased bleeding tendencies. Providing a stool softener helps prevent constipation, reducing the likelihood of straining during bowel movements and subsequent bleeding. Encouraging the client to floss daily (choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (choice B) pertains more to infection control than addressing thrombocytopenia. Avoiding serving raw vegetables (choice D) is not directly associated with managing thrombocytopenia symptoms.

3. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?

Correct answer: A

Rationale: In a client who is 30 minutes postoperative following an arterial thrombectomy, chest pain is a critical finding that should be reported immediately. Chest pain can indicate serious complications such as myocardial infarction or pulmonary embolism, which require prompt intervention. Muscle spasms and cool, moist skin are not typical signs of immediate concern following an arterial thrombectomy. Incisional pain is expected postoperatively and may not warrant immediate reporting unless accompanied by other concerning symptoms.

4. A nurse is teaching a prenatal class about infections. Which statement by a participant indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. This statement indicates a need for further teaching because antibiotics are ineffective against viral infections. It is important to educate the participant that antibiotics are only effective against bacterial infections, not viral ones. Choices A, B, and D are correct statements that promote good hygiene practices and infection prevention during pregnancy.

5. A nurse is assessing a client who is 1 hour postoperative following a hysterectomy. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: A heart rate of 78/min is within the normal range; however, postoperative patients require close monitoring for any signs of complications. While the heart rate is normal, other critical findings such as increased pain, excessive bleeding, or other concerning symptoms may need immediate attention. Choices B, C, and D all indicate normal postoperative vital signs and oxygen saturation levels, which do not raise immediate concerns requiring reporting to the provider.

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