which of the following is an expected finding during the assessment of a client transitioning into a new role
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. What is an expected finding during the assessment of a client transitioning into a new role?

Correct answer: B

Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.

2. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Correct answer: A

Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.

3. A patient prescribed warfarin is being taught about dietary restrictions by a healthcare provider. Which of the following foods should the patient be instructed to limit?

Correct answer: B

Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which can interfere with the effectiveness of warfarin, an anticoagulant medication. Patients taking warfarin should limit foods high in vitamin K to maintain the medication's effectiveness and consistent dosage. Bananas, potatoes, and apples are not high in vitamin K and do not typically interfere with warfarin therapy.

4. What is the most appropriate intervention for a client experiencing acute alcohol withdrawal?

Correct answer: B

Rationale: The most appropriate intervention for a client experiencing acute alcohol withdrawal is to administer diazepam. Diazepam is a benzodiazepine commonly used to prevent seizures and manage the symptoms of alcohol withdrawal. Encouraging physical activity may not be safe during acute withdrawal as the client may be at risk for seizures and other complications. Monitoring for signs of dehydration is important but not the most immediate intervention needed in acute alcohol withdrawal. While encouraging the client to verbalize their feelings is beneficial for therapeutic communication, it is not the priority intervention when managing acute alcohol withdrawal.

5. When working with a client who does not speak the same language, which of the following actions should the nurse take?

Correct answer: C

Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.

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