ATI PN Adult Medical Surgical 2019

ATI PN Adult Medical Surgical 2019 Related

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An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?

  • A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
  • B. The UAP should be reassigned to another group of residents, preferably females only.
  • C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
  • D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct Answer: C

Rationale: The correct answer is C because the behavior exhibited by the resident may stem from touch deprivation rather than being intentional sexual harassment. Here's a step-by-step rationale:
1. Understanding the resident's age and environment (extended care facility) helps in interpreting his behavior.
2. The resident's actions suggest a need for touch, which is common in older adults who may lack physical contact.
3. Educating the resident on appropriate ways to express his need for touch can address the underlying issue.
4. Reassigning the UAP or reporting the incident as sexual harassment (options A and B) may not address the root cause of the behavior and could potentially harm the resident's well-being.
In summary, choice C focuses on addressing the resident's potential touch deprivation in a compassionate and understanding manner, making it the best assessment of the situation.

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A client with severe rheumatoid arthritis is experiencing joint pain and stiffness. Which intervention should the nurse implement to help relieve the client's symptoms?

  • A. Apply cold packs to the affected joints.
  • B. Encourage passive range-of-motion exercises.
  • C. Administer a muscle relaxant.
  • D. Provide a high-calorie diet.
Correct Answer: B

Rationale: The correct answer is B: Encourage passive range-of-motion exercises. This intervention helps improve joint mobility, reduce stiffness, and alleviate pain in clients with rheumatoid arthritis. Passive range-of-motion exercises can prevent joint contractures and maintain joint function. Applying cold packs (A) may help reduce inflammation but does not address joint stiffness. Administering a muscle relaxant (C) is not typically indicated for rheumatoid arthritis. Providing a high-calorie diet (D) is important for overall health but does not directly address joint pain and stiffness in this case.

A client with a history of gout is experiencing an acute attack. Which medication should the nurse expect the healthcare provider to prescribe?

  • A. Aspirin.
  • B. Allopurinol (Zyloprim).
  • C. Colchicine.
  • D. Probenecid (Benemid).
Correct Answer: C

Rationale: The correct answer is C: Colchicine. Colchicine is used to treat acute gout attacks by reducing inflammation and pain. It works by decreasing the inflammatory response to urate crystals in the joints. Aspirin (choice A) is not recommended for gout treatment as it can worsen symptoms. Allopurinol (choice B) and Probenecid (choice D) are used for long-term management of gout by reducing uric acid levels and preventing future attacks, not for acute attacks. Colchicine is the appropriate choice for treating the client's acute gout symptoms.

A client with left-sided heart failure is experiencing dyspnea and orthopnea. Which position should the nurse place the client in to relieve these symptoms?

  • A. High Fowler's position.
  • B. Supine position.
  • C. Trendelenburg position.
  • D. Sims' position.
Correct Answer: A

Rationale: The correct answer is A: High Fowler's position. Placing the client in a High Fowler's position helps reduce dyspnea and orthopnea by facilitating lung expansion and improving ventilation. In this position, the client's head and chest are elevated at a 90-degree angle, allowing for maximal chest expansion and improved oxygenation. This position also helps reduce the workload on the heart by decreasing venous return, which can help alleviate symptoms of left-sided heart failure.

Summary:
- A: High Fowler's position is correct as it facilitates lung expansion and improves ventilation.
- B: Supine position would not be ideal as it can exacerbate symptoms by increasing pressure on the lungs and heart.
- C: Trendelenburg position would worsen symptoms by increasing venous return and fluid overload.
- D: Sims' position is used for procedures or to facilitate drainage, not for relieving dyspnea and orthopnea.

The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?

  • A. Thickened and hardened skin.
  • B. Painless ulcers on the fingertips.
  • C. Episodes of cyanosis and pallor in the fingers.
  • D. Red, scaly patches on the hands.
Correct Answer: C

Rationale: The correct answer is C: Episodes of cyanosis and pallor in the fingers. Raynaud's phenomenon is characterized by vasospasms of small arteries, leading to reduced blood flow and color changes in the digits. Cyanosis (bluish discoloration) and pallor (pale color) are common during episodes. Thickened and hardened skin (A) is associated with scleroderma. Painless ulcers on the fingertips (B) are seen in advanced stages of systemic sclerosis. Red, scaly patches on the hands (D) are indicative of psoriasis, not Raynaud's phenomenon.

A client with a history of myocardial infarction (MI) is prescribed atorvastatin (Lipitor). Which outcome indicates that the medication is effective?

  • A. Increased blood pressure.
  • B. Lowered cholesterol levels.
  • C. Decreased heart rate.
  • D. Improved liver function.
Correct Answer: B

Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a statin medication used to lower cholesterol levels, reducing the risk of further cardiovascular events in patients with a history of MI. Lowering cholesterol helps prevent plaque buildup in arteries, reducing the likelihood of another MI. Increased blood pressure (A) and decreased heart rate (C) are not direct indicators of atorvastatin's effectiveness. Improved liver function (D) may be a consideration due to potential side effects, but the primary goal of atorvastatin is to lower cholesterol levels to prevent cardiovascular events.

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