ATI RN
ATI Mental Health
1. Which of the following interventions should not be included in the care plan for a client with major depressive disorder?
- A. Encourage participation in activities
- B. Promote adequate nutrition and hydration
- C. Discourage verbalization of feelings
- D. Monitor for suicidal ideation
Correct answer: C
Rationale: Interventions for a client with major depressive disorder should focus on promoting activities, adequate nutrition, hydration, and monitoring for suicidal ideation. Verbalizing feelings is a crucial part of therapy for clients with depression as it helps in processing emotions and seeking support. Therefore, discouraging verbalization of feelings is not appropriate and goes against therapeutic principles.
2. A client is receiving warfarin for atrial fibrillation. Which of the following laboratory tests should the nurse expect to be ordered to monitor the effect of warfarin?
- A. Platelet count
- B. International normalized ratio (INR)
- C. Prothrombin time (PT)
- D. Partial thromboplastin time (PTT)
Correct answer: B
Rationale: The correct answer is B: International normalized ratio (INR). When a client is on warfarin therapy, the INR is monitored regularly to assess the anticoagulant effects of the medication. A therapeutic INR range for most indications is between 2.0 to 3.0. Choices A, C, and D are not typically used to monitor the effect of warfarin. Platelet count assesses the number of platelets in the blood, PT measures the clotting time of plasma, and PTT evaluates the intrinsic pathway of coagulation.
3. What is the best intervention for a patient experiencing respiratory distress?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Administer IV fluids
- D. Reposition the patient
Correct answer: A
Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation. Oxygen therapy is the initial and priority intervention to ensure an adequate oxygen supply to the body tissues. Administering bronchodilators (Choice B) may be appropriate for specific respiratory conditions like asthma or COPD but is not the first-line intervention in all cases of respiratory distress. Administering IV fluids (Choice C) is not a standard intervention for respiratory distress unless there is an underlying cause like dehydration. Repositioning the patient (Choice D) can aid in optimizing ventilation but is not the primary intervention for respiratory distress.
4. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess first?
- A. The client with three (3) unifocal PVCs in a minute
- B. The client diagnosed with coronary artery disease who wants to ambulate
- C. The client diagnosed with mitral valve prolapse with an audible S3
- D. The client diagnosed with pericarditis who is in normal sinus rhythm
Correct answer: C
Rationale: The correct answer is C because an audible S3 in a client with mitral valve prolapse could indicate heart failure and requires immediate assessment. Choice A is not as urgent as an audible S3 in mitral valve prolapse. Choice B, a client with coronary artery disease wanting to ambulate, does not present an immediate concern compared to a potential heart failure indicated by an audible S3. Choice D, a client with pericarditis in normal sinus rhythm, is stable and does not require immediate attention when compared to a potential heart failure situation signified by an audible S3 in mitral valve prolapse.
5. What is the best nursing action for a patient experiencing shortness of breath?
- A. Administer oxygen
- B. Administer bronchodilators
- C. Reposition the patient
- D. Provide IV fluids
Correct answer: A
Rationale: Administering oxygen is the best nursing action for a patient experiencing shortness of breath as it helps alleviate the symptoms and improve oxygenation. Providing oxygen addresses the primary issue of inadequate oxygen levels in the body, which can be a life-threatening situation. Administering bronchodilators (choice B) may be appropriate for specific respiratory conditions like asthma but is not the initial intervention for all causes of shortness of breath. Repositioning the patient (choice C) can sometimes help improve breathing, but in a patient experiencing significant shortness of breath, immediate oxygen therapy is crucial. Providing IV fluids (choice D) is not indicated as the first-line intervention for shortness of breath unless there is a specific underlying cause such as dehydration.
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