ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The nurse is performing a psychosocial assessment on a client with a severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?
- A. “Tell me about what medication you are taking”
- B. “What physical limitations are you experiencing?”
- C. “How does this impact your role in your family?”
- D. “What therapies are you using to reduce swelling?”
Correct answer: “How does this impact your role in your family?”
Rationale:
2. A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?
- A. Implement a no-harm contract with the client.
- B. Monitor the client closely for signs of self-harm.
- C. Encourage the client to participate in recreational activities.
- D. Encourage the client to maintain a structured daily routine.
Correct answer: A
Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.
3. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. Which of the following group facilitation techniques should the nurse include in the teaching?
- A. Share personal opinions to help influence the group's values.
- B. Measure the accomplishments of the group against a previous group.
- C. Yield in situations of conflicts to maintain group harmony.
- D. Use modeling to help the clients improve their interpersonal skills.
Correct answer: D
Rationale: The correct answer is D: 'Use modeling to help the clients improve their interpersonal skills.' Modeling is an effective therapeutic technique where the leader demonstrates appropriate behaviors for the group to learn from. This technique can help clients improve their interpersonal skills by observing and replicating positive behaviors. Choices A, B, and C are incorrect. Sharing personal opinions to influence the group's values may not be appropriate as it could hinder the group dynamics and individual autonomy. Comparing accomplishments against a previous group is not a recommended technique as each group is unique, and comparisons may not be beneficial. Yielding in conflicts to maintain group harmony may lead to unresolved issues and hinder the group's progress.
4. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?
- A. Age and gender
- B. High-fat diet, smoking, alcohol consumption
- C. Ethnicity and race
- D. Exposure to radiation
Correct answer: B
Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.
5. A client is prescribed Propranolol for a dysrhythmia. Which of the following actions should the nurse plan to take?
- A. Hold Propranolol if the client's apical pulse is greater than 100/min.
- B. Administer Propranolol to decrease the client's blood pressure.
- C. Assist the client with sitting up or standing after taking this medication.
- D. Monitor the client for hypokalemia due to the risk of Propranolol toxicity.
Correct answer: C
Rationale: The correct action the nurse should plan to take when administering Propranolol is to assist the client when sitting up or standing after taking the medication. Propranolol can lead to orthostatic hypotension, causing dizziness upon sudden position changes. It is essential to help the client with position changes to prevent falls or injury. Holding Propranolol if the client's apical pulse is greater than 100/min (Choice A) is incorrect because Propranolol is often used to manage dysrhythmias and slowing down the heart rate. Administering Propranolol to decrease the client's blood pressure (Choice B) is not the primary indication for using this medication. Monitoring the client for hypokalemia due to the risk of Propranolol toxicity (Choice D) is not a direct effect of Propranolol; rather, it is more related to other medications like diuretics.
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