ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client states, “Why am I getting protein supplements while I am healing from a bed sore?” What is the best response by the nurse?
- A. ‘Because it is easy to digest.’
- B. ‘Protein has amin acid that promotes wound healing.’
- C. ‘If you do not like it, you do not have to take it.’
- D. ‘These supplements have nothing to do with your wound,’
Correct answer: ‘Protein has amin acid that promotes wound healing.’
Rationale:
2. A nurse is providing care for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?
- A. Psychologist
- B. Social worker
- C. Occupational therapist
- D. Speech-language pathologist
Correct answer: D
Rationale: In the advanced stage of ALS, clients often experience swallowing difficulties, known as dysphagia. A speech-language pathologist specializes in assessing and managing these swallowing problems, making them the nurse's priority referral in this case. A psychologist primarily focuses on mental health and emotional well-being, which may not be the most critical issue at this stage. Social workers assist with social support and resources, while occupational therapists help with activities of daily living and mobility, which are important but not the priority when dysphagia is a concern.
3. What role do hormones play in mental health and behavior?
- A. Hormones only affect physical processes, not mental health.
- B. Hormones play a critical role in regulating mood, behavior, and mental health.
- C. Hormones have no effect on behavior.
- D. Hormones are only involved in reproductive processes.
Correct answer: B
Rationale: Hormones play a critical role in regulating mood, behavior, and mental health, influencing everything from stress response to emotional stability. Choice A is incorrect because hormones have a significant impact on mental health in addition to physical processes. Choice C is incorrect as hormones do have a notable effect on behavior. Choice D is incorrect as hormones have broad functions beyond just reproductive processes.
4. A client is experiencing a panic attack. Which action should the nurse take first?
- A. Remain with the client and offer reassurance.
- B. Administer an anti-anxiety medication as prescribed.
- C. Encourage the client to engage in physical activity.
- D. Encourage the client to breathe deeply and slowly.
Correct answer: A
Rationale: During a panic attack, the immediate priority for the nurse is to provide support and reassurance to the client. Remaining with the client helps establish a sense of safety and trust, which can help calm the client during an episode of panic. Administering medication, encouraging physical activity, and deep breathing techniques are beneficial interventions, but offering reassurance and support should be the initial step to address the immediate emotional distress and anxiety experienced by the client.
5. What is the priority nursing action when a patient with chest pain presents with possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check the patient's cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The priority nursing action when a patient with chest pain presents with possible acute coronary syndrome is to administer sublingual nitroglycerin. Sublingual nitroglycerin helps dilate blood vessels, reducing cardiac workload, and improving blood supply to the heart muscle, thus relieving pain and enhancing blood flow to the heart. While obtaining IV access is important for administering medications and fluids, it is not the priority over addressing pain and improving blood flow. Checking the patient's cardiac enzymes is crucial for diagnosis and ongoing management but not the immediate priority when the patient is in pain. Administering aspirin is also a vital intervention in acute coronary syndrome, but in this scenario, it is not the priority action compared to providing immediate pain relief and enhancing blood flow to the heart.
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