ATI RN
Theory of Health Behavior Change Questions
Question 1 of 5
Nurse Patricia finds a female client who is post-myocardial infarction (MI) slumped on the side rails of the bed and unresponsive to shaking or shouting. Which is the nurse next action?
Correct Answer: A
Rationale: The correct answer is A: Call for help and note the time. In this scenario, the nurse should first ensure the client's safety by calling for assistance to manage the situation effectively. This step is crucial to provide timely and appropriate care for the unresponsive post-MI client. Clearing the airway (B) and administering physical interventions (C, D) should only be done after calling for help to ensure that the client receives necessary support and interventions promptly.
Question 2 of 5
Nurse Greta is working on a surgical floor. Nurse Greta must logroll a client following a:
Correct Answer: A
Rationale: Correct Answer: A (Laminectomy) Rationale: 1. Laminectomy involves surgical removal of a portion of the vertebral bone to relieve pressure on the spinal cord or nerves. 2. Logrolling is necessary post-laminectomy to prevent injury to the surgical site and maintain spinal alignment. 3. Clients post-laminectomy are at risk for spinal cord damage if not logrolled properly. Summary: B: Thoracotomy involves accessing the chest cavity, not the spine. C: Hemorrhoidectomy involves removal of hemorrhoids, not spinal surgery. D: Cystectomy involves removal of the bladder, not the spine.
Question 3 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 4 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 5 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.