ATI RN
Theoretical Basis for Behavior Modification Questions
Question 1 of 5
You continuously evaluate the client's adaptation to pain. Which of the following behaviors indicate appropriate adaptation?
Correct Answer: C
Rationale: The correct answer is C because distraction during pain episodes is a healthy coping mechanism that indicates appropriate adaptation to pain. This behavior suggests the client is able to manage pain without it significantly impacting their daily functioning. A: Reporting pain reduction and decreased activity may indicate maladaptive coping or worsening pain. B: Denying pain can be a sign of maladaptive coping or psychological distress. D: Reporting independence from watchers does not necessarily indicate effective pain adaptation and may be unrelated to pain management.
Question 2 of 5
Which of the following nursing actions should be initiated first?
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 6L/min. This should be initiated first because it addresses the client's immediate physiological need for oxygenation, ensuring adequate oxygen supply to vital organs. Providing oxygen takes precedence over emotional support (A), suctioning (C), and administering bronchodilators (D). Emotional support is important but not as urgent as oxygenation. Suctioning and administering bronchodilators are secondary interventions once oxygenation is optimized. Administering oxygen first is essential in managing respiratory distress and ensuring the client's safety and stability.
Question 3 of 5
As a nurse, you know you can improve on accuracy of patient's identification by 2 patient identifiers, EXCEPT:
Correct Answer: C
Rationale: The correct answer is C. Calling the client by their case and bed number is not considered an effective way to improve accuracy of patient identification. Here's the rationale: 1. Patient identifiers should be unique to the individual, so using case and bed number are not specific enough. 2. Wrist tags are a common and reliable method for patient identification. 3. Verifying with family members or calling the patient by their name ensures accuracy. 4. Using both wrist tags and calling the patient by name reinforces identification. In summary, choice C lacks specificity and does not provide a direct link to the patient, unlike the other options provided.
Question 4 of 5
The following are appropriate nursing interventions during colostomy irrigation EXCEPT:
Correct Answer: A
Rationale: Correct Answer: A Rationale: A) Increasing the flow rate when abdominal cramps occur can lead to discomfort and potential injury to the stoma. Instead, the flow rate should be adjusted to a comfortable level. B) Inserting 2-4 inches of lubricated catheter helps ensure proper irrigation without causing trauma to the stoma. C) Positioning the client in semi-Fowler aids in comfort and proper visualization during the procedure. D) Hanging the solution 18 inches above the stoma creates the appropriate pressure for effective irrigation without causing discomfort or excessive pressure on the stoma.
Question 5 of 5
A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?
Correct Answer: C
Rationale: The correct answer is C because checking respirations first ensures airway patency and oxygenation. Stabilizing the spine prevents further injury, and checking circulation assesses perfusion. Option A misses spine stabilization, B focuses on spine alignment before airway, and D does not address spine stability promptly. Prioritizing airway, breathing, and circulation is crucial in emergency care to ensure client safety and prevent complications.