ATI RN
ATI Mental Health
1. A client is being taught relaxation techniques to manage anxiety. Which of the following techniques should not be included in the teaching? Select all that apply.
- A. Deep breathing exercises
- B. Progressive muscle relaxation
- C. Mindfulness meditation
- D. Cognitive restructuring
Correct answer: D
Rationale: Deep breathing exercises, progressive muscle relaxation, and mindfulness meditation are commonly used relaxation techniques to manage anxiety. Cognitive restructuring is a cognitive-behavioral technique aimed at changing negative thought patterns and beliefs, not a relaxation technique. It focuses on altering cognitive distortions rather than inducing physical relaxation responses.
2. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:
- A. Provide nutrients
- B. Increase protein stores
- C. Elevate the circulating blood volume
- D. Divert blood flow away from the liver temporarily
Correct answer: C
Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.
3. Examination of the abdomen is performed correctly by the nurse in which order?
- A. Inspection, palpation, percussion, and auscultation
- B. Inspection, percussion, auscultation, and palpation
- C. Palpation, percussion, auscultation, and inspection
- D. Inspection, auscultation, percussion, and palpation
Correct answer: D
Rationale: The correct order for abdominal examination is inspection, auscult
4. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?
- A. Instruct the client to delay intercourse until menses
- B. Schedule the client for frequent pelvic sonograms
- C. Explain that the infusion therapy will take 21 days
- D. Discuss that this may cause an ectopic pregnancy
Correct answer: B
Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (choice A) is not directly related to monitoring or managing ovarian hyperstimulation. Explaining the duration of infusion therapy (choice C) is not relevant to the potential complication of ovarian hyperstimulation. Discussing the risk of ectopic pregnancy (choice D) is important but not the most appropriate intervention for managing ovarian hyperstimulation.
5. A client receiving continuous enteral tube feeding reports cramping and abdominal distention. Which of the following actions should the nurse take?
- A. Check for gastric residual.
- B. Apply low intermittent suction.
- C. Increase the rate of the feeding.
- D. Request a higher-fat formula.
Correct answer: A
Rationale: When a client on continuous enteral tube feeding experiences cramping and abdominal distention, the nurse should check for gastric residual. This assessment helps determine if the client is tolerating the feeding well or if there is a potential issue such as feeding intolerance. Applying low intermittent suction, increasing the feeding rate, or requesting a higher-fat formula are not appropriate actions for addressing the reported symptoms and may exacerbate the client's discomfort or lead to further complications.
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