which of the following nursing interventions is most appropriate for a client experiencing severe anxiety which of the following nursing interventions is most appropriate for a client experiencing severe anxiety
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. Which of the following interventions is most appropriate for a client experiencing severe anxiety?

Correct answer: B

Rationale: In cases of severe anxiety, creating a quiet and calm environment is crucial as it can help reduce stimulation and promote relaxation. This environment can provide a sense of safety and security, which are essential for individuals experiencing heightened anxiety levels. Encouraging the client to talk about their feelings may not be suitable during severe anxiety as it can further escalate distress by focusing on the source of anxiety. Vigorous exercise and group activities may not be appropriate initially, as they can increase arousal levels rather than promoting a sense of calm needed to manage severe anxiety.

2. What are the manifestations of nephrotic syndrome?

Correct answer: C

Rationale: Infection is a common manifestation of nephrotic syndrome. This is due to the loss of immunoglobulins in the urine, which weakens the body's immune defenses. Dehydration (Choice A) and uremia (Choice B) can be symptoms of kidney dysfunction but are not specific manifestations of nephrotic syndrome. Low blood lipids (Choice D) is incorrect as nephrotic syndrome typically results in high, not low, blood lipid levels due to the body's attempt to replace lost proteins.

3. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

4. What diagnostic procedure uses sound waves to create images of the heart and assess its structure and function?

Correct answer: A

Rationale: An echocardiogram is the correct answer because it is a diagnostic procedure that uses sound waves to create images of the heart, enabling doctors to assess its structure and function. This imaging technique is specifically designed for cardiac assessment. MRI (Choice B), CT scan (Choice C), and X-ray (Choice D) are imaging modalities that are not primarily used for detailed evaluation of the heart's structure and function, making them incorrect choices for this question.

5. A client is brought to the emergency department after a motor vehicle accident in which she suffered a spinal cord injury at the level of C5. Which of the following assessments should be the priority?

Correct answer: B

Rationale: The correct answer is monitoring heart rate and rhythm. With a C5 spinal cord injury, monitoring heart rate and rhythm is crucial as it can impact autonomic regulation. This level of injury can affect cardiac function due to the disruption of sympathetic nerve fibers. Monitoring urinary output may be important to assess for urinary retention, but it is not the priority in this scenario. While monitoring respiratory rate is essential in all patients, in this case, cardiovascular stability takes precedence. Pain management is important but is not the priority when assessing a client with a C5 spinal cord injury.

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