a nurse is reviewing information about advance directives with a newly admitted client which statement by the client indicates an understanding of the a nurse is reviewing information about advance directives with a newly admitted client which statement by the client indicates an understanding of the
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

2. A client with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). Which instruction should the nurse include in the client's teaching?

Correct answer: B

Rationale: The correct instruction for the nurse to include in the teaching for a client prescribed tiotropium (Spiriva) is to rinse the mouth after using the inhaler. Rinsing the mouth helps prevent oral thrush, a common side effect of inhaled medications. This action reduces the risk of developing oral fungal infections, promoting better oral health for the client.

3. A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?

Correct answer: C

Rationale: Insulin glargine is classified as a long-acting insulin. It is designed to provide a consistent level of insulin over approximately 24 hours, helping to keep blood glucose levels stable throughout the day. This long duration of action makes it suitable for basal insulin replacement in patients with type 1 diabetes, providing a background level of insulin to mimic the body's natural release of insulin between meals and overnight.

4. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

Correct answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

5. What intervention should the nurse implement when caring for a patient demonstrating manic behavior?

Correct answer: D

Rationale: When caring for a patient demonstrating manic behavior, the nurse should implement the intervention of reducing environmental stimuli and creating a calm atmosphere. This approach is crucial in managing manic behavior as it helps decrease triggers that may worsen the patient's symptoms. Engaging the patient in calming activities (Choice B) may not be effective during a manic episode as the patient may have difficulty focusing. While offering a quiet environment for relaxation (Choice C) is beneficial, it may not be sufficient to address the heightened stimulation experienced during mania. Monitoring the patient’s vital signs frequently (Choice A) is important in general patient care but may not directly address the specific needs of a patient exhibiting manic behavior.

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