ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 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.
Question 2 of 5
A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing:
Correct Answer: B
Rationale: The correct answer is B: Depression. The patient's symptoms such as being easily distracted, recent life changes, and the loss of his pet suggest a mood disorder rather than a cognitive impairment like dementia (A) or delirium (C). The patient's alertness and ability to engage in conversation indicate that he is not experiencing delirium. Additionally, the patient's medical history of diabetes makes a hypoglycemic reaction (D) less likely, as he is alert during the assessment. Depression is a common comorbidity in patients with chronic illnesses like osteoarthritis and diabetes, and the recent life stressors could exacerbate his depressive symptoms.
Question 3 of 5
Within how many feet of oxygen administration is smoking not allowed?
Correct Answer: B
Rationale: The correct answer is B: 12 feet. This distance is established to prevent fires as oxygen supports combustion. Smoking within 12 feet of oxygen administration poses a significant fire hazard. Choice A (4 meters) is incorrect as it is greater than 12 feet. Choices C and D are incorrect as they do not provide a specific distance requirement.
Question 4 of 5
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
Correct Answer: D
Rationale: The correct answer is D: Battery. Battery in the context of tort law is the intentional and unauthorized physical contact with another person that results in harm or offense. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes unauthorized physical contact, making it a clear example of battery. This act goes against the client's autonomy and right to refuse treatment. A: Assault involves the threat of physical harm, not the actual physical contact seen in this scenario. B: False imprisonment involves restricting someone's freedom of movement, which is not applicable here. C: Negligence refers to a breach of duty of care resulting in harm, but in this case, the action is intentional, not negligent.
Question 5 of 5
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.