ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse cares for a patient, who has been taking ibuprofen for back pain x 3 weeks, was admitted to the hospital for abdominal pain. Which assessment data takes priority?
Correct Answer: C
Rationale: Rationale: 1. Occult blood in stool can indicate gastrointestinal bleeding, a serious complication of prolonged ibuprofen use. 2. Gastrointestinal bleeding can lead to anemia, hypovolemia, and shock. 3. Promptly addressing bleeding is crucial to prevent further complications. 4. Diarrhea, Hematuria, and Ova & Parasites are less likely related to ibuprofen use for back pain and are not immediate priorities.
Question 5 of 5
The nurse is developing a plan of care for a client with disturbed body image. Which interventions would the nurse most likely include in the plan? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A (Establish rapport with the client) because building a trusting relationship is essential in addressing disturbed body image. By establishing rapport, the nurse can create a safe environment for the client to express their feelings and concerns. Choice B (Role model appropriate behavior) may not directly address the client's distorted body image issues and might not be as effective as building rapport. Choice C (Encourage client to make positive self-statements) may be helpful in boosting self-esteem, but it may not address the underlying causes of the disturbed body image. Choice D (Assist the client in accepting responsibility for own actions) is not directly related to addressing disturbed body image and may not be as effective as building rapport in this context.