while working in a long term care facility the nurse notices that older residents take pleasure in telling stories about their earlier lives and reliv while working in a long term care facility the nurse notices that older residents take pleasure in telling stories about their earlier lives and reliv
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Nursing Elites

ATI LPN

ATI Leadership Proctored Exam 2019

1. While working in a long-term care facility, the nurse notices that older residents take pleasure in telling stories about their earlier lives and reliving special events. The nurse recognizes this helps residents meet which level of Maslow's Hierarchy of needs?

Correct answer: D

Rationale: The act of telling stories and reliving special events by the older residents in the long-term care facility helps them achieve self-actualization. Self-actualization involves realizing personal potential, self-fulfillment, seeking personal growth, and reflecting on their lives and achievements, which aligns with the behavior observed by the nurse. Choices A, B, and C are incorrect because self-esteem is related to confidence and respect, love and belonging refer to social relationships and connections, and safety pertains to physical and psychological security, which are not directly addressed by the residents' behavior of storytelling and reliving special events.

2. The client with Raynaud's phenomenon is being taught by the nurse about preventing episodes. Which instruction should the nurse reinforce?

Correct answer: A

Rationale: The correct answer is A: 'Wear gloves in cold weather.' Wearing gloves in cold weather is essential for preventing vasoconstriction and subsequent episodes of Raynaud's phenomenon. Cold temperatures can trigger vasospasms in individuals with Raynaud's, and wearing gloves helps maintain warmth and prevent the constriction of blood vessels in the extremities, reducing the likelihood of an episode. Choices B, C, and D are incorrect because while avoiding caffeine and chocolate, increasing vitamin C intake, and using a heating pad for warmth can be beneficial for overall health, they are not specifically targeted at preventing Raynaud's phenomenon episodes triggered by cold weather.

3. A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?

Correct answer: B

Rationale: A newborn's respiratory rate can vary between 20 to 100 breaths per minute during the initial phase after birth. A respiratory rate as low as 18 breaths per minute at this early stage requires immediate nursing intervention. This finding necessitates further assessment to ensure adequate oxygenation and respiratory function. The other options, heart rate of 168/min, tremors, and fine crackles, are within normal limits for a full-term newborn and do not require immediate intervention.

4. A woman at 38 weeks of gestation is admitted in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

Correct answer: C

Rationale: An elevated temperature in a woman with ruptured membranes may indicate infection. Assessing the odor of the amniotic fluid can help determine if chorioamnionitis (an infection of the amniotic fluid) is present. This assessment is crucial to guide further interventions and management of the client's condition. Options A, B, and D are incorrect. Rechecking the client's temperature in 4 hours does not address the immediate concern of potential infection. Administering glucocorticoids intramuscularly is not indicated based solely on an elevated temperature. Preparing the client for an emergency cesarean section is premature and not supported by the information provided.

5. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

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