ATI RN
Client Safety Nursing Skill Template Questions
Question 1 of 5
Your patient is a 17-year-old client who lost her right leg in a motor vehicle accident. After her parents leave, she asks you, 'Why did God let this happen to me? I have always followed his commandments.' Which action best depicts the 'Caring' aspect of SENC? Explain your thinking.
Correct Answer: D
Rationale: The correct answer is D: Hold her hand. This action best depicts the 'Caring' aspect of SENC (Support, Encourage, Nurture, and Coach). By holding her hand, you are providing physical comfort and emotional support, showing empathy and understanding. This gesture conveys a sense of presence and solidarity, helping the client feel heard and valued. Calling the parents back (A) may not be appropriate without the client's consent. Referring to the Chaplain (B) may not address the immediate emotional needs. Crying with the client (C) may blur professional boundaries and not necessarily provide the necessary support.
Question 2 of 5
An older adult client has been moved from home to a skilled nursing facility (SNF). Which behavior, demonstrated by this client, indicates a problem with daily functioning?
Correct Answer: D
Rationale: The correct answer is D because refusing to use the prescribed walker indicates a problem with mobility and safety, which are crucial aspects of daily functioning for an older adult. This behavior can lead to an increased risk of falls and injury. A: Eating 80% of meals shows the client's ability to engage in self-care. B: Watching television with others is a social activity and does not necessarily indicate a problem with daily functioning. C: Wanting to wear one's own clothing is a personal preference and does not directly affect daily functioning. In summary, answer choice D is correct because it directly impacts the client's ability to function independently and safely, while the other choices are less critical in determining daily functioning issues.
Question 3 of 5
A family has recently immigrated to the United States. All members are quickly learning the language and the children are all in public school. Both parents are working and adapting to the new culture. What is this family demonstrating?
Correct Answer: B
Rationale: The correct answer is B: Cultural assimilation. This family is actively adapting to the new culture by learning the language, enrolling children in public school, and adjusting to the work environment. Cultural assimilation involves integrating into a new culture while retaining some aspects of the original culture. This family is not experiencing culture shock (A) because they are gradually adjusting, not in a state of distress. They are not displaying cultural blindness (C) as they are aware of and adapting to the new culture. Lastly, cultural imposition (D) refers to forcing one's own culture onto others, which is not the case here.
Question 4 of 5
Which of the following client situation is appropriate to delegate to a (n) unlicensed assistive personnel (UAP)? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A because assisting a client with a 1:1 feeding is within the scope of practice for unlicensed assistive personnel (UAP). UAPs can provide basic assistance with feeding under the supervision of a licensed nurse. This task does not require specialized nursing skills. Choice B is incorrect because emptying a foley catheter drainage bag involves a sterile procedure that should be performed by a licensed nurse. Choice C is incorrect as assessing a client with new onset shortness of breath and taking vital signs requires critical thinking and clinical judgment, which are beyond the scope of practice for UAPs. Choice D is incorrect because providing information about discharge home health services involves patient education and coordination of care, which are responsibilities of the licensed nurse or healthcare provider.
Question 5 of 5
A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to:
Correct Answer: C
Rationale: The correct answer is C: Call adult protective services because you suspect elder mistreatment. In this scenario, the patient's presentation raises concerns for elder abuse, as evidenced by the presence of a stage 3 pressure ulcer, old bruising, and the patient's unkempt appearance. By involving adult protective services, the nurse can initiate an investigation to ensure the safety and well-being of the patient. This step is crucial in addressing potential abuse and protecting the vulnerable adult. Summary: A: Calling social services for nursing home placement is premature without investigating the suspected abuse. B: Asking the son to step out may not address the potential abuse and could hinder the assessment. D: While assessing cognitive status is important, addressing suspected elder mistreatment takes precedence in this situation.