ATI RN
ATI RN Community Health 2023 with NGN Updated Questions
Extract:
Question 1 of 5
A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply)
Correct Answer: B, C, E
Rationale: The correct interventions for chemotherapy-induced nausea are B, C, E. B: Ginger ale can help alleviate nausea. C: Elevating the head after eating can prevent reflux. E: Guided imagery can distract from nausea. A: Seasonings may worsen nausea. D: Cold milk can trigger nausea in some clients.
Therefore, A and D are incorrect due to potential exacerbation of symptoms.
Question 2 of 5
A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
Correct Answer: A
Rationale: The correct answer is A: Test for the presence of the client's gag reflex. This action is essential when providing oral care to an unconscious client to prevent aspiration. Testing for the gag reflex helps determine if the client can protect their airway. If the gag reflex is present, it indicates that the client's airway is protected, and oral care can be safely provided. Placing the client in the supine position (choice
B) could increase the risk of aspiration. Using a firm toothbrush (choice
C) can injure the client's gums and oral tissues. Using 2 gauze-wrapped fingers to hold the mouth open (choice
D) can potentially cause harm or discomfort to the client. Testing for the gag reflex is the safest and most appropriate action to ensure the client's safety during oral care.
Question 3 of 5
A hospice nurse is talking with the partner of a client who is near death. The partner states, 'How will I go on without them? I already feel alone.' Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Express sympathy to the client's partner. The nurse should acknowledge and validate the partner's feelings of grief and loneliness. This shows empathy and support, which are crucial in this situation.
Choice B may be seen as too generic and may not address the partner's emotional needs directly.
Choice C, hugging, may not be appropriate for all individuals and could be intrusive.
Choice D, reassuring that it will get better, may invalidate the partner's current emotions and minimize their feelings. It is important to provide emotional support and validation in times of grief and loss.
Question 4 of 5
A home health nurse is planning the initial home visit for a client who has dementia and lives with his adult son's family. Which of the following actions should the nurse take first during the visit?
Correct Answer: D
Rationale: The correct answer is D: Engage the family in informal conversation. The first step for the nurse should be to establish a rapport with the family members and the client to build trust and gather valuable information about their daily routines, challenges, and needs. Engaging in informal conversation allows the nurse to assess the family's understanding of the client's condition, their coping mechanisms, and their support system. It also helps in identifying potential stressors and developing a personalized care plan.
The other choices are incorrect because:
A: Encouraging the family to join a support group may be beneficial but should come after establishing a relationship and understanding their specific needs.
B: Providing information about respite care is important but should be addressed once the nurse has assessed the family's immediate concerns.
C: Educating the family about the progression of dementia is crucial, but it is not the first step during the initial visit.
In summary, engaging in informal conversation is the most appropriate initial action to gather information and build a
Question 5 of 5
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This should be the first action because understanding the roles within the family can provide insight into how they are coping and functioning post-loss. By determining roles, the nurse can assess the dynamics and identify potential areas of support needed. Referring to a grief support group (
A) may be beneficial later but not until the nurse understands the family dynamics. Encouraging specific tasks (
C) and establishing a daily routine (
D) are important steps but should come after understanding individual roles.