ATI LPN
ATI PN Adult Medical Surgical 2019
1. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct answer: B
Rationale: Initiating short, frequent contacts with the client is the most appropriate action to promote trust. This approach helps build trust and rapport, addressing the client's need for security. By maintaining regular contact, the nurse can provide reassurance and support, which can help alleviate the client's anxiety related to her delusional beliefs. Choice A does not directly address the client's need for trust and security. Choice C focuses on the client's illness but does not actively address building trust. Choice D, offering to keep the belongings at the nurse's desk, may not be well-received by the client and could potentially worsen her anxiety and distrust.
2. What is the legal basis of the Primary Health Care approach in the Philippines?
- A. Alma Ata Declaration on PHC
- B. Letter of Instruction No. 949
- C. Presidential Decree No. 147
- D. Presidential Decree No. 996
Correct answer: B
Rationale: The correct answer is B, the Letter of Instruction No. 949. This instruction was issued by then President Ferdinand Marcos, directing the Ministry of Health (now the Department of Health) to utilize the Primary Health Care approach in planning and implementing health programs. This legal basis established the foundation for implementing Primary Health Care in the Philippines, aligning with the global Alma Ata Declaration's principles.
3. A healthcare professional is assessing a client for signs of stroke. Which of the following should the healthcare professional look for?
- A. Slurred speech
- B. Increased appetite
- C. Elevated heart rate
- D. Hyperactivity
Correct answer: A
Rationale: Corrected Question: A healthcare professional is assessing a client for signs of stroke. Slurred speech is a common sign of stroke and should be assessed immediately. Choices B, C, and D are incorrect because increased appetite, elevated heart rate, and hyperactivity are not typical signs of a stroke.
4. A client with a history of angina pectoris reports chest pain while ambulating in the corridor. What should the nurse do first?
- A. Check the client's vital signs.
- B. Assist the client to sit or lie down.
- C. Administer sublingual nitroglycerin.
- D. Apply nasal oxygen at a rate of 2 L/min.
Correct answer: B
Rationale: When a client with a history of angina pectoris experiences chest pain while ambulating, the priority action for the nurse is to assist the client to sit or lie down. This helps reduce the demand on the heart by decreasing physical exertion. Checking vital signs, administering medication, or applying oxygen can follow once the client is in a more comfortable position. Checking vital signs (Choice A) may be important but addressing the immediate discomfort by positioning the client comfortably takes precedence. Administering sublingual nitroglycerin (Choice C) is appropriate but should come after ensuring the client's comfort. Applying nasal oxygen (Choice D) can be beneficial, but it should not be the first action; assisting the client to sit or lie down is the initial priority.
5. A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
- A. Your baby will have excess baby fat.
- B. Your baby will have flat areola without breast buds.
- C. Your baby's heels will easily move to his ears.
- D. Your baby's skin will have a leathery appearance.
Correct answer: D
Rationale: The correct answer is D: 'Your baby's skin will have a leathery appearance.' Postmature infants, born after 42 weeks of gestation, may have a leathery appearance of the skin due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa is shed, and the skin loses its protective covering, leading to a wrinkled and dry appearance. Choices A, B, and C are incorrect. Excess baby fat is not a typical characteristic of postmature infants. Flat areola without breast buds and the ability of the baby's heels to easily move to his ears are not associated with postmaturity.
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