how should a nurse manage a patient with suspected myocardial infarction mi
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023

1. How should a healthcare professional manage a patient with suspected myocardial infarction (MI)?

Correct answer: A

Rationale: Administering oxygen and seeking emergency help are crucial initial steps in managing a patient with suspected myocardial infarction (MI). Oxygen helps to improve oxygenation to the heart muscle, reducing its workload and preventing further damage. Calling for emergency help ensures timely access to advanced medical care, including interventions like thrombolytics. Monitoring vital signs and providing pain relief are important but secondary to the immediate need for oxygen and emergency assistance. Providing nitroglycerin and thrombolytics should be done under medical supervision and following appropriate protocols, not as the first step. Administering diuretics and altering the patient's diet are not indicated in the acute management of MI.

2. A nurse is teaching a client who is undergoing chemotherapy about measures to prevent infection. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid crowded places. Immunocompromised clients undergoing chemotherapy are at a higher risk of infections, so avoiding crowded places can help reduce exposure to pathogens. Wearing a mask at home is not necessary unless someone in the household is sick. Drinking unfiltered water can introduce harmful bacteria, increasing the risk of infection. Avoiding washing hands frequently is incorrect as hand hygiene is crucial in preventing the spread of infections.

3. How do you assess for dehydration in a pediatric patient?

Correct answer: A

Rationale: Correct! When assessing for dehydration in a pediatric patient, checking for dry mouth and decreased urine output are crucial indicators. Dry mouth indicates reduced fluid intake or dehydration, while decreased urine output suggests decreased renal perfusion secondary to dehydration. Skin turgor and capillary refill are more indicative of perfusion status rather than dehydration specifically. Lethargy and irritability can be present in dehydrated patients but are more general signs of illness. Monitoring blood pressure and heart rate are important in assessing dehydration severity but are not the initial signs used for assessment.

4. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?

Correct answer: B

Rationale: In cases where a child's injuries are inconsistent with the parent's stated cause, it raises concerns about possible abuse. The correct action for the nurse in this situation is to report suspected abuse to the appropriate agency. This is a legal and ethical obligation for healthcare professionals when they suspect child abuse. Providing teaching to the parents (Choice A) may not address the immediate safety concerns of the child. Documenting the injuries and monitoring the child (Choice C) is important but reporting suspected abuse takes precedence to ensure the child's safety. Counseling the parents privately (Choice D) may not be effective if abuse is suspected, as the primary focus should be on protecting the child.

5. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?

Correct answer: B

Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.

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