ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
Sleep comfort, wrong.
Correct Answer: A
Rationale: The correct answer is A: Make patient tired before sleeping. This is because physical and mental exhaustion can improve sleep quality. By engaging in activities that make the patient tired, such as exercise or mental stimulation, they are more likely to fall asleep faster and have a deeper, more restful sleep. Providing milk, as in choice B, may be relaxing for some individuals, but it is not a guaranteed method to improve sleep comfort. Choice C and D are left blank, as they do not offer any relevant information related to improving sleep comfort.
Question 2 of 5
Nail cutting
Correct Answer: A
Rationale: The correct answer is A: Follow the curve. This is because nails naturally grow in a curved shape, so cutting them following the curve helps prevent ingrown nails and maintains the nail's natural shape. Cutting straight (option B) can increase the risk of ingrown nails and discomfort. Options C and D are incomplete, so they are incorrect choices. Following the curve when cutting nails is the most effective and safe approach for maintaining healthy nails.
Question 3 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 4 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 5 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.