ATI Clinical Exam

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Nurse's Notes & Physical Examination
• The client is found attempting to climb out of bed, stating, "People are trying to hurt me." They are highly agitated and disoriented, attempting to remove IV lines. The client's behavior is erratic, and they require constant supervision. The skin is now cool and pale, with poor capillary refill. Respirations are labored, and the client is using accessory muscles to breathe. Lung sounds have deteriorated, with coarse crackles heard throughout. The abdomen is firm, and the client expresses significant discomfort. The urinary catheter output has decreased, and urine appears concentrated.
Vital Signs
• Blood Pressure: 100/64 mm Hg
• Temperature: 37.3° C (99.1° F)
• Pulse: 110/min
• Respirations: 28/min
Diagnostic Results
• Hemoglobin: 12.5 g/dL
• Hematocrit: 38.0%
• AST: 52 units/L
• ALT: 49 units/L
Provider's Prescriptions
• Soft wrist restraints if necessary.
• Immediate reassessment and adjustment of care plan.
2100 hrs - Critical Incident

A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?

  • A. I will apply elastic bandages to cuts.
  • B. I will use dishwashing gloves when cleaning the dishes.
  • C. I will use ink pens for writing.
  • D. I will buy balloons for my son's birthday.
Correct Answer: D

Rationale: The correct answer is D. Latex allergy can be triggered by latex balloons. Therefore, buying balloons for the son's birthday could potentially expose the client to latex, leading to an allergic reaction. Elastic bandages, dishwashing gloves, and ink pens are typically latex-free alternatives. The other choices are incorrect because they do not involve direct exposure to latex.

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A nurse is formulating a care plan for a patient recovering from severe burns. Which of the following strategies should the nurse incorporate to provide emotional support? Which strategy provides emotional support for burn recovery?

  • A. Engage in conversation with the patient during wound care.
  • B. Ensure the patient's room is kept tidy by support staff.
  • C. Keep the patient's family informed about his condition.
  • D. Rotate the nursing staff to provide the patient with varied interactions.
Correct Answer: A

Rationale: The correct answer is A: Engage in conversation with the patient during wound care. This strategy provides emotional support by offering the patient a distraction and a sense of connection during a potentially painful and distressing procedure. It allows the patient to express their feelings and concerns, fostering a therapeutic relationship.

Choice B: Ensuring the patient's room is tidy is important for the patient's physical comfort but does not directly address emotional support.

Choice C: Keeping the patient's family informed is crucial for communication but may not directly provide emotional support to the patient.

Choice D: Rotating nursing staff may offer varied interactions, but consistency and building rapport with the same caregiver can be more beneficial for emotional support in this context.

A nurse assumes various roles while working with patients. Which of the following describes the nursing role of protecting the patient and supporting the patient's decisions? Which role involves protecting and supporting patient decisions?

  • A. Advocate
  • B. Manager
  • C. Caregiver
  • D. Educator
Correct Answer: A

Rationale: The correct answer is A: Advocate. Nurses act as advocates by protecting the patient's rights, ensuring their voice is heard, and supporting their decisions. Advocacy involves standing up for the patient's best interests and promoting autonomy. The other choices are incorrect because: B: Manager focuses on organizing and coordinating care, C: Caregiver involves providing direct physical and emotional care, and D: Educator focuses on providing information and teaching. Advocacy uniquely encompasses protecting and supporting the patient's decisions, making it the most appropriate choice in this scenario.

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson's stages of psychosocial development in order from birth to adolescence. Arrange Erikson's stages from birth to adolescence.

  • A. Identity vs. role confusion
  • B. Trust vs. mistrust
  • C. Industry vs. inferiority
  • D. Autonomy vs. shame and doubt
  • E. Initiative vs. guilt
Correct Answer: B,D,E,C,A

Rationale: 1. Trust vs. mistrust comes first as it pertains to infancy and the development of basic trust in caregivers.
2. Autonomy vs. shame and doubt follows, focusing on toddlers developing independence.
3. Initiative vs. guilt is next, focusing on preschoolers exploring and taking initiative.
4. Industry vs. inferiority is about school-aged children developing competence.
5. Identity vs. role confusion is about adolescents forming a sense of self.
Therefore, the correct order is B, D, E, C, A. Other choices are incorrect as they do not align with the chronological order of Erikson's stages.

A nurse is caring for a patient who is postoperative following a thyroidectomy. Which of the following findings should the nurse monitor for? Which finding should the nurse monitor post-thyroidectomy?

  • A. Hypotension
  • B. Tachycardia
  • C. Hyperglycemia
  • D. Bradypnea
Correct Answer: B

Rationale: The correct answer is B: Tachycardia. Following a thyroidectomy, the nurse should monitor for tachycardia due to the risk of thyroid storm, which can cause increased heart rate. Hypotension (A) is less common post-thyroidectomy. Hyperglycemia (C) is not a typical finding post-thyroidectomy. Bradypnea (D) is not expected, as respiratory rate should be monitored for signs of airway obstruction.

A nurse is caring for a client who has nausea and a prescription for metoclopramide intravenously every 8 hours as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which explanation should the nurse provide?How does metoclopramide relieve nausea?

  • A. The medication relieves nausea by promoting gastric emptying.
  • B. The medication works by relaxing gastric muscles.
  • C. The medication works by decreasing gastric acid secretions.
  • D. The medication enhances gastric emptying.
Correct Answer: A,D

Rationale: The correct answers are A and D. Metoclopramide relieves nausea by promoting gastric emptying, which helps move food through the stomach faster. This action reduces the feeling of fullness and discomfort, ultimately alleviating nausea. Additionally, enhancing gastric emptying helps prevent reflux, which can contribute to nausea. Choices B and C are incorrect because metoclopramide does not work by relaxing gastric muscles or decreasing gastric acid secretions. These mechanisms do not directly address the issue of delayed gastric emptying, which is the primary reason for nausea relief with metoclopramide.

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