ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 9
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 2 of 9
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?
Correct Answer: D
Rationale: The correct answer is D: Assisting with tracheostomy insertion. Subcutaneous emphysema traveling up the neck indicates potential airway compromise. Tracheostomy insertion may be necessary to secure the airway and prevent further complications. Surgery (choice A) may not address the immediate need for securing the airway. Encouraging the client to use the Incentive Spirometer (IS) (choice B) or palpating the area (choice C) would not address the urgency of the situation or provide a definitive solution to the airway compromise.
Question 3 of 9
Fifth vital sign
Correct Answer: B
Rationale: The fifth vital sign is pain, which is typically measured using a numerical scale. Walking on thumb tacks causes physical pain, making it an appropriate example of the fifth vital sign. Tasting spicy food does not involve physical pain and is not a vital sign. Therefore, the correct answer is B. Walking on thumb tacks.
Question 4 of 9
Maintenance of fluid balance in the patient with ARDS involves
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct: 1. ARDS patients have increased capillary permeability leading to fluid leakage into the lungs. 2. Mild fluid restriction helps prevent fluid overload and pulmonary edema. 3. Diuretics help manage any excess fluid accumulation. 4. Hydration using colloids (choice A) can exacerbate fluid overload. 5. Surfactant (choice B) is used in neonatal respiratory distress syndrome, not ARDS. 6. Keeping hemoglobin level >12 g/dL (choice D) is unrelated to fluid balance in ARDS.
Question 5 of 9
In relationship to the nurse's ability to communicate with a client, which type of communication most effectively demonstrates professional competence?
Correct Answer: C
Rationale: The correct answer is C: Interpersonal. Interpersonal communication involves direct interaction between the nurse and client, showcasing active listening, empathy, and respect. This type of communication fosters trust, understanding, and therapeutic relationships, reflecting professional competence. Public communication (A) involves addressing large audiences and may lack the personal connection needed in client interactions. Small group communication (B) involves communication within a limited group and may not be as focused on individual client needs. Intrapersonal communication (D) refers to self-talk and reflection, which is important but not directly related to communicating with clients.
Question 6 of 9
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.
Question 7 of 9
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
Correct Answer: C
Rationale: The correct answer is C: Palpate pulses. This task should be assigned first because assessing the pulses can provide crucial information about the injured workers' circulation and perfusion status. By palpating pulses, the unlicensed assistive personnel can quickly identify any signs of compromised circulation or potential life-threatening conditions. This immediate assessment is essential for prioritizing care and determining the urgency of further interventions. Other choices are incorrect because: A: Getting temperatures can be important but not as immediately critical as assessing pulses for circulatory status. B: Taking blood pressure may provide valuable information, but assessing pulses gives a more direct indication of perfusion. D: Checking alertness is important, but assessing pulses should be the priority for immediate life-saving interventions.
Question 8 of 9
What is the leading cause of injury-related deaths in adults 65 and older?
Correct Answer: A
Rationale: The correct answer is A: Falls. Older adults are at higher risk of falls due to factors like decreased balance and mobility. Falls are the leading cause of injury-related deaths in this age group. Violence (B) is less common, alcoholism (C) is a health issue but not the leading cause of injury-related deaths, and MVAs (D) are more common in younger age groups.
Question 9 of 9
The health-care provider ordered STAT arterial blood gases for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client without taking any action. The ABG results indicate a pH within the normal range (7.35-7.45), PaO2 is slightly lower than normal but still adequate for tissue oxygenation, PaCO2 is within the normal range (35-45), and HCO3 is normal (22-26). These values indicate that the client's acid-base balance is within normal limits, and no immediate intervention is needed. Encouraging deep breaths and coughing (B) may be beneficial for some respiratory conditions but is not indicated here. Administering sodium bicarbonate IVP (C) is unnecessary as the client's pH and HCO3 levels are normal. Notifying the respiratory therapist (D) is not warranted since the ABG results do not indicate any acute respiratory distress. Monitoring the client (A) is the appropriate action as the ABG results are stable.