ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with Parkinson's disease is being cared for by a nurse. Which intervention should be included to address the client's bradykinesia?
- A. Encourage daily walking.
- B. Provide thickened liquids to prevent aspiration.
- C. Offer small, frequent meals.
- D. Teach the client to use adaptive utensils.
Correct answer: A
Rationale: Encouraging daily walking is an essential intervention to address bradykinesia in clients with Parkinson's disease. Walking helps improve mobility, flexibility, and coordination, which can help manage the slowness of movement associated with bradykinesia. Providing thickened liquids (Choice B) is more relevant for dysphagia, not bradykinesia. Offering small, frequent meals (Choice C) is related to managing dysphagia and nutritional needs but does not specifically address bradykinesia. Teaching the client to use adaptive utensils (Choice D) is more focused on addressing fine motor skills and grip strength, which are not the primary concerns in bradykinesia.
2. Which nursing intervention is best for a client with constipation?
- A. Encourage the client to remain in bed to avoid straining
- B. Administer a stool softener as prescribed
- C. Increase fiber intake through dietary changes
- D. Encourage regular exercise to promote bowel movement
Correct answer: C
Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.
3. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include?
- A. Document the client's condition every 15 minutes.
- B. Attach the restraints to a non-moving part of the bed.
- C. Avoid requesting a PRN restraint prescription for clients who are aggressive.
- D. Remove the client's restraints based on the client's condition.
Correct answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. When using belt restraints, it is crucial to document the client's condition regularly to ensure their safety and well-being. This guideline allows for ongoing assessment of the client's need for restraints and any potential adverse effects. Choice B is incorrect as restraints should not be attached to the bed frame but to a non-moving part of the bed to prevent harm in case of bed movement. Choice C is incorrect as PRN (as needed) restraint prescription should not be a routine practice and should only be considered after other interventions have been attempted. Choice D is incorrect as restraints should be removed and reevaluated based on the client's condition, not solely on a fixed time schedule.
4. When in doubt about using restraints on an agitated patient, it is prudent for nurses to:
- A. Restrain the patient for their own safety
- B. Use minor restraints such as a bed side rail or a tray on a wheelchair
- C. Use alternatives such as a bed alarm with increased staff supervision
- D. Avoid using any device or procedure to limit liability
Correct answer: C
Rationale: The correct answer is C: 'Use alternatives such as a bed alarm with increased staff supervision.' The Omnibus Budget Reconciliation Act (OBRA) established strict standards on restraint use in long-term care facilities. Restraints can be considered a form of false imprisonment and neglect, leading to potential litigation. Therefore, it is advisable to avoid restraints whenever possible. A bed alarm coupled with enhanced staff supervision provides an effective and non-restrictive approach for managing an agitated patient. Choices A, B, and D are incorrect because restraining the patient, using minor restraints, or avoiding all devices without providing an alternative can pose risks to patient safety, violate regulations, or increase liability concerns.
5. A client with chronic heart failure has been prescribed furosemide (Lasix). Which instruction should the nurse reinforce to the client regarding this medication?
- A. Take the medication with food.
- B. Limit foods high in potassium while taking this medication.
- C. Report any muscle cramps or weakness to your healthcare provider.
- D. Expect to urinate more frequently while on this medication.
Correct answer: C
Rationale: The correct instruction for the nurse to reinforce to the client regarding furosemide (Lasix) is to report any muscle cramps or weakness to the healthcare provider. Muscle cramps or weakness may indicate hypokalemia, a potential side effect of furosemide. Monitoring and reporting these symptoms promptly can help in preventing complications related to electrolyte imbalances. Choice A is incorrect because furosemide should be taken on an empty stomach. Choice B is not directly related to furosemide use; in fact, foods high in potassium may be beneficial for clients taking furosemide to prevent hypokalemia. Choice D is a common expected side effect of furosemide due to its diuretic action but is not as crucial to report as potential signs of electrolyte imbalances.
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