ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a serious complication where air enters the pleural space causing lung collapse. Administering oxygen is important to support oxygenation, but the next priority is to address the potential pneumothorax. Inserting a chest tube helps drain the air from the pleural space and re-expand the lung, stabilizing the client's condition. Sublingual nitroglycerin is not indicated for this situation as it is used for chest pain related to cardiac issues. Placing a sterile dressing over the IV site and re-positioning into Trendelenburg position are not appropriate actions for managing a suspected pneumothorax.
Question 2 of 5
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?
Correct Answer: B
Rationale: The correct answer is B: Note escalating behaviors and intervene immediately. This is the priority as the client is exhibiting signs of acute psychosis, indicating a risk to their safety. By noting escalating behaviors and intervening immediately, the nurse can prevent potential harm to the client or others.
Assessing for medication noncompliance (
Choice
A) is important but not the priority in this acute situation. Interpreting attempts at communication (
Choice
C) can be done after ensuring immediate safety. Assessing triggers for bizarre behaviors (
Choice
D) is not as urgent as intervening to prevent harm.
Question 3 of 5
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
Correct Answer: C
Rationale: The correct answer is C: Restlessness and muscle rigidity. Benztropine is an anticholinergic medication commonly used to treat extrapyramidal symptoms such as restlessness and muscle rigidity, which can occur as side effects of antipsychotic medications like haloperidol. Tactile hallucinations (choice
A) would not be a direct indication for benztropine. Tardive dyskinesia (choice
B) is a late side effect of antipsychotic medications and is not an acute symptom requiring benztropine. Reports of hearing disturbing voices (choice
D) are indicative of auditory hallucinations, which would not be treated with benztropine.
Question 4 of 5
Two adult siblings are caring for their ill mother, who requires 24-hour care: she needs assistance with feeding, bathing, and toileting. One of the siblings takes time to exercise after work. The other sibling goes directly to the mother's home before and after work each day. The nurse recognizes that people may react differently to the same stressors depending on various factors. What are some of these factors? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Amount of perceived stress. This is because individuals may react differently to stressors based on how they perceive the level of stress they are experiencing. Factors such as previous experiences, personality, and support systems can influence how stress is perceived. Hair color (
B) and skin type (
D) are not relevant factors in how individuals react to stress. Individual coping skills (
C) are important, but they are more about how individuals manage stress rather than how they initially perceive it.
Question 5 of 5
The nurse cares for a client who just had a massive myocardial infarction (MI). Which of the following stress reduction techniques would be applicable to this client? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Promote a heart healthy diet. Following a heart-healthy diet can help manage risk factors for further cardiac events. A diet high in fruits, vegetables, whole grains, lean proteins, and low in saturated fats can help reduce cholesterol levels and blood pressure.
Choices B, C, and D are incorrect. B: Encouraging cigarette cessation is crucial as smoking increases the risk of further cardiovascular issues. C: While sleep is important, the immediate focus should be on heart health interventions. D: After a massive MI, low-intensity exercise may not be safe until the client's condition stabilizes.