an older adult has a diagnosis of alzheimer disease and has recently been experiencing fecal incontinence however the nurse has observed no recent cha
Logo

Nursing Elites

ATI LPN

Medical Surgical ATI Proctored Exam

1. An older adult with a diagnosis of Alzheimer's disease has been experiencing fecal incontinence, with no recent change in stool character noted by the nurse. What is the nurse's most appropriate intervention?

Correct answer: C

Rationale: The most appropriate intervention for an older adult with Alzheimer's disease experiencing fecal incontinence and no change in stool character is to toilet the client on a frequent, scheduled basis. Scheduled toileting can help manage incontinence by establishing a routine for bowel movements, which may aid in reducing episodes of fecal incontinence.

2. A client with a history of chronic alcohol abuse is at risk for which of the following conditions?

Correct answer: A

Rationale: Chronic alcohol abuse can lead to liver cirrhosis due to long-term liver damage. Alcohol consumption over time can cause inflammation and scarring of the liver, eventually leading to cirrhosis. This condition can severely impact liver function and may progress to liver failure if not addressed.

3. A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?

Correct answer: D

Rationale: Teaching the individual to limit sugar and caffeine intake is an appropriate intervention to reduce anxiety and improve sleep quality. Sugar and caffeine can exacerbate anxiety symptoms and disrupt sleep patterns. By reducing their intake, the individual may experience a decrease in anxiety levels and better sleep. Encouraging daily rituals, reinforcing financial realities, or suggesting alcohol consumption before bed are not evidence-based strategies for managing anxiety and sleeplessness.

4. The client with gastroesophageal reflux disease (GERD) is being taught about dietary modifications by the nurse. Which instruction should the nurse include?

Correct answer: B

Rationale: Avoiding lying down immediately after eating is essential in managing GERD as it helps prevent reflux symptoms by allowing gravity to assist in keeping stomach contents down. Lying down can worsen symptoms by allowing acid to flow back into the esophagus.

5. What action should the nurse take for a patient admitted with diabetic ketoacidosis exhibiting rapid, deep respirations?

Correct answer: C

Rationale: The correct action for a patient with diabetic ketoacidosis and rapid, deep (Kussmaul) respirations is to administer a normal saline bolus and insulin. The rapid, deep respirations indicate a metabolic acidosis, which requires correction with a saline bolus to prevent hypovolemia and insulin to facilitate glucose re-entry into cells. Oxygen therapy is not necessary since the increased respiratory rate is compensatory and not due to hypoxemia. Encouraging relaxation techniques or administering lorazepam are inappropriate as they can worsen the acidosis by suppressing the compensatory respiratory effort.

Similar Questions

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?
What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?
A patient with chronic obstructive pulmonary disease (COPD) is experiencing severe dyspnea. What position should the nurse encourage the patient to assume?
A client with diabetes has a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that should be prepared in the insulin syringe?
A 65-year-old man presents with weight loss, jaundice, and a palpable mass in the right upper quadrant. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses