what physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum what physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum
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ATI Medical Surgical Proctored Exam 2019 Quizlet

1. What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Correct answer: C

Rationale: The correct answer is C. A pulse rate of 56 BPM can be considered a normal finding for a primigravida client who is 12 hours postpartum. Postpartum bradycardia can occur due to increased stroke volume and decreased vascular resistance after delivery. It is important for the nurse to monitor the client's vital signs and recognize that a lower pulse rate can be expected in the immediate postpartum period. Choices A, B, and D are incorrect because a soft, spongy fundus may indicate uterine atony, saturating two perineal pads per hour is excessive bleeding, and unilateral lower leg pain could suggest deep vein thrombosis, all of which would require further assessment and intervention.

2. A client with cirrhosis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. In cirrhosis, decreasing the intake of sodium-rich foods is essential to manage fluid retention and symptoms. Excessive sodium intake can worsen fluid accumulation and lead to complications such as ascites. Therefore, advising the client to decrease sodium-rich foods demonstrates an understanding of the dietary management necessary for cirrhosis. Choices A, C, and D are incorrect because increasing sodium-rich foods can exacerbate fluid retention and complications in cirrhosis, increasing potassium-rich foods is not the primary focus of dietary management in cirrhosis, and decreasing potassium-rich foods is not a key recommendation for managing cirrhosis-related dietary issues.

3. A client is undergoing systematic desensitization for an extreme fear of elevators. Which of the following actions should be implemented with this form of therapy?

Correct answer: C

Rationale: Systematic desensitization is a type of therapy used to help individuals overcome phobias or anxieties. It involves gradually exposing the client to the feared object or situation, in this case, an elevator, while simultaneously practicing relaxation techniques. This process helps the client associate relaxation with the previously feared stimulus, gradually reducing anxiety levels over time. Choice A is incorrect as it involves imitation rather than gradual exposure. Choice B is incorrect as it focuses on a verbal response rather than the systematic process of exposure and relaxation. Choice D is incorrect as it does not involve the systematic approach of gradually exposing the client while teaching relaxation techniques.

4. Which symptom is most characteristic of generalized anxiety disorder (GAD)?

Correct answer: B

Rationale: Excessive worrying about various aspects of life is a hallmark symptom of generalized anxiety disorder (GAD). In GAD, individuals experience excessive and uncontrollable worry about a wide range of everyday problems. This persistent worrying can lead to physical and emotional symptoms, impacting their daily functioning and quality of life. Fear of social situations, hallucinations, and impulsive behaviors are not typically associated with GAD.

5. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?

Correct answer: C

Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.

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