a patient reports feeling dizzy when standing up what is the most appropriate nursing intervention
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?

Correct answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

2. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?

Correct answer: B

Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.

3. A nurse observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?

Correct answer: D

Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.

4. A family was referred to crisis intervention services after a natural disaster. One family member refuses to attend, stating, 'No way, I'm not crazy.' What is the nurse's best response?

Correct answer: D

Rationale: The nurse should reassure the family member that seeking help does not imply mental illness, but is part of coping with the disaster.

5. What is the primary focus of secondary prevention in community mental health care?

Correct answer: B

Rationale: The correct answer is B: Early detection of mental illness. Secondary prevention in community mental health care focuses on identifying mental health issues at an early stage to provide timely interventions. Choice A, teaching stress-reduction techniques, is more aligned with primary prevention aimed at preventing the onset of mental health problems. Choice C, leading support groups for clients with substance use disorder, pertains more to providing specific interventions for individuals with substance use issues rather than the general focus of secondary prevention. Choice D, rehabilitation and prevention of further issues, is more related to tertiary prevention, which involves addressing existing mental health conditions and preventing complications or recurrence.

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