Questions 48

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ATI Msn De5320 Fundamentals Exam Questions

Extract:


Question 1 of 5

The nurse identified that the patient has pain of 7 on a scale of 1 to 10 and he expresses discomfort over the incisional area. He guards the area by resisting movement. Which component is the S in a three-part nursing diagnostic statement using the PES format? Nursing Diagnosis: Acute pain r/t incisional trauma with guarding and restricted movement

Correct Answer: C

Rationale: In the PES format, ‘S’ (Signs/Symptoms) includes observable evidence like guarding and restricted movement. Acute pain is the problem, incisional trauma the etiology, and swelling is not mentioned.

Question 2 of 5

A nurse is caring for a client who reports experiencing flashbacks of a traumatic event that occurred a year ago. The nurse should identify that the client is experiencing which of the following stress-related disorders?

Correct Answer: D

Rationale: PTSD causes long-term flashbacks post-trauma, matching a year-long duration. ASD is short-term, episodic acute stress isn’t a diagnosis, and IBS is unrelated to psychological trauma.

Question 3 of 5

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

Correct Answer: A

Rationale: Dual diagnosis treatment addresses both antisocial personality disorder and alcohol dependency with integrated care. Codependency support is for families, psychodrama explores emotions, and crisis intervention is short-term.

Question 4 of 5

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Locking bed wheels ensures stability during transfer, enhancing safety. A 90° chair angle complicates movement, the chair should be on the strong side, and raising the bed excessively risks unsafe positioning.

Question 5 of 5

Which nursing action would be appropriate to protect a patient during a seizure?

Correct Answer: A,B,D,E

Rationale: Padding the head, avoiding oral objects, turning to the side, and using pillows prevent injury and aspiration. Moving to bed during a seizure risks harm.

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