ATI RN
Theory of Health Behavior Change Questions
Question 1 of 5
Marichu was given morphine sulfate for pain. She is sleeping and her respiratory rate is 4 breaths/minute. If action isn't taken quickly, she might have which of the following reactions?
Correct Answer: B
Rationale: The correct answer is B: Respiratory arrest. Morphine sulfate is a potent opioid that can depress the central nervous system, including the respiratory system. A respiratory rate of 4 breaths/minute is dangerously low and can lead to respiratory arrest if not addressed promptly. This can result in a complete cessation of breathing, leading to serious consequences like hypoxia and potentially death. Choice A: Asthma attack is incorrect because morphine sulfate does not typically cause asthma attacks. Choice C: Seizure is incorrect as respiratory depression is more likely to occur before a seizure in this scenario. Choice D: Wake up on his own is incorrect because the dangerously low respiratory rate indicates a serious medical emergency requiring immediate intervention.
Question 2 of 5
Nurse Maureen is talking to a male client, the client begins choking on his lunch. He's coughing forcefully. The nurse should:
Correct Answer: D
Rationale: The correct answer is D because the client is coughing forcefully, which indicates that he is still able to clear his airway on his own. By staying with him but not intervening at this time, the nurse can monitor his condition and be ready to intervene if the choking worsens. Standing him up or laying him down to perform the abdominal thrust maneuver can potentially make the situation worse if the client is still able to cough and clear his airway. Leaving him to get assistance is not appropriate as the nurse should stay with the client to provide support and monitor the situation. Straddling him to perform the maneuver is also not recommended as it can be intimidating and may not be necessary if the client is managing to cough.
Question 3 of 5
After several days of admission, Francis becomes disoriented and complains of frequent headaches. The nurse in-charge first action would be:
Correct Answer: A
Rationale: The correct answer is A: Call the physician. This is the most appropriate action because the patient's symptoms of disorientation and frequent headaches may indicate a serious underlying medical issue that requires immediate attention from the physician. Documenting the patient's status (B) can be done after addressing the immediate concern. Oxygen treatment (C) may not be necessary without further assessment by the physician. Raising the side rails (D) is not a priority when the patient is experiencing concerning symptoms. Calling the physician ensures timely intervention and appropriate medical management for the patient's condition.
Question 4 of 5
Lydia undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
Correct Answer: D
Rationale: The correct answer is D: "Keep the stoma moist." This is because keeping the stoma moist helps prevent dryness and irritation, promotes healing, and helps maintain the patency of the airway. Moisture also aids in preventing crust formation, which can obstruct the airway. A: "Keep the stoma uncovered" is incorrect as covering the stoma helps protect it from debris and infection. B: "Keep the stoma dry" is incorrect as moisture is necessary for proper healing and to prevent blockages. C: "Have a family member perform stoma care initially until you get used to the procedure" is incorrect as the client should learn how to perform stoma care themselves for independence and self-care.
Question 5 of 5
Nurse Cecile is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?
Correct Answer: C
Rationale: The correct answer is C because it emphasizes the importance of obtaining the recommended daily allowance of calcium from a variety of foods. Calcium is essential for bone health and can be found in dairy products, leafy greens, nuts, and fortified foods. This teaching point promotes a balanced and healthy diet as a natural way to prevent osteoporosis. Choice A is incorrect because routine X-rays are not recommended for detecting bone loss in osteoporosis. Choice B is incorrect as regular exercise, including weight-bearing and resistance training, is beneficial for bone health and can help prevent fractures. Choice D is incorrect as it is possible to meet the daily calcium requirement through dietary sources without necessarily needing a calcium supplement.