a nurse working in a mobile health clinic is assessing a migrant farm worker which of the following findings should the nurse identify as the priority
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. While assessing a migrant farm worker in a mobile health clinic, which of the following findings should the nurse identify as the priority?

Correct answer: D

Rationale: The correct answer is D because muscle twitching and a rash could indicate pesticide poisoning, a serious condition that requires immediate attention in a migrant farm worker. Option A is not the priority as it could be musculoskeletal in nature and managed after addressing urgent issues. Option B, absence of a dental health provider, though important for overall health, is not an immediate priority. Option C, living with 25 other migrant workers, raises concerns about living conditions but does not present an immediate health threat compared to potential pesticide poisoning.

2. The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?

Correct answer: C

Rationale: The correct answer is C because documenting bilateral radial pulses being present, 2+, and hands warm to the touch is crucial when caring for a patient in restraints. This information helps in monitoring circulation and assessing the patient's well-being. Choices A, B, and D are incorrect because they do not provide essential information related to the patient's safety and well-being while in restraints.

3. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?

Correct answer: B

Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.

4. A female client with anxiety disorder is being taught about alprazolam by a nurse. Which of the following information should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B. Alprazolam can increase the risk of pregnancy complications, so using a reliable form of contraception is essential to prevent unintended pregnancies. Choice A is incorrect because alprazolam typically does not increase blood pressure. Choice C is incorrect as doubling the next dose after a missed dose can lead to overdose and adverse effects. Choice D is unrelated to alprazolam and is not a concern when taking this medication.

5. A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following a total hysterectomy. Which of the following information should the nurse include?

Correct answer: C

Rationale: The correct information the nurse should include is that menopausal hormone therapy helps prevent osteoporotic fractures by maintaining bone density. Option A is incorrect as hormone therapy should be taken consistently at the same time each day for optimal effectiveness. Option B is incorrect as menopausal hormone therapy is not primarily aimed at preventing cerebral hemorrhage. Option D is incorrect because taking an extra dose is not recommended if a dose is missed; instead, the missed dose should be taken as soon as remembered, unless it is close to the time for the next dose.

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