ATI RN
Nursing Care of Children Final ATI
1. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)
- A. All below
- B. Considering alternative actions
- C. Using formal and informal thinking to gather data
- D. Giving deliberate thought to a patient's problem
Correct answer: A
Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.
2. A patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain?
- A. Meditation alters the chemical composition of pain neuroregulators, which closes the gate.
- B. Meditation stops the occurrence of pain stimuli.
- C. Meditation controls pain by blocking pain impulses from coming through the gate.
- D. Meditation will help me sleep through the pain because it opens the gate.
Correct answer: C
Rationale: The correct answer is C. According to the gate control theory, meditation helps relieve pain by blocking pain impulses from coming through the gate in the central nervous system. Choice A is incorrect as meditation does not directly alter the chemical composition of pain neuroregulators. Choice B is incorrect because meditation does not stop the occurrence of pain stimuli. Choice D is incorrect as meditation does not open the gate but rather closes it to block pain impulses.
3. A client with schizophrenia is pacing the hall and is agitated. Which of the following actions should the nurse take?
- A. Ask the client if they intend to harm others.
- B. Tell the client to stop pacing the hall.
- C. Allow the client to pace alone until they feel less anxious.
- D. Walk with the client at a gradually slower pace.
Correct answer: D
Rationale: The correct action for the nurse to take when caring for a client with schizophrenia who is pacing the hall and agitated is to walk with the client at a gradually slower pace. This approach can help reduce the client's agitation and prevent the situation from escalating. Choice A is incorrect because directly asking about harm may increase the client's anxiety. Choice B is inappropriate as it may worsen the client's agitation. Choice C is not recommended as the client may benefit from the nurse's presence and support during this time of distress.
4. What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.
5. Which of the following is a characteristic of the human immunodeficiency virus (HIV), which causes AIDS?
- A. HIV only infects B cells
- B. HIV is a retrovirus
- C. Infection does not require a host cell receptor
- D. After infection, cell death is immediate
Correct answer: B
Rationale: The correct answer is B. HIV is a retrovirus that infects T cells and leads to the gradual destruction of the immune system. Choice A is incorrect because HIV infects T cells primarily, not just B cells. Choice C is incorrect because HIV infection requires host cell receptors for entry. Choice D is incorrect because cell death after HIV infection is not immediate; instead, the virus gradually weakens the immune system over time.
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