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ATI PN Management 2023
Total Questions : 60
Showing 10 questions, Sign in for moreA nurse is completing a preoperative checklist for a client. The client tells the nurse. "I am not sure if I want the procedure after all." Which of the following responses should the nurse make?
A nurse receives a change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?
A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?
A nurse is receiving a telephone prescription from a provider for propranolol 40 mg PO BID. When reading back the information to the provider, which of the following actions should the nurse take?
0800:
Client who has a history of schizophrenia is having persecutory delusions and command hallucinations.
1200:
Client reports they know the agents are watching every move they make. "They will come get me. The voices tell me the actions I should take."
0730:
Client has a 7 year history of major depressive disorder. Family reports the client has stopped taking their medication and become isolated, withdrawn, cries all the time, sleeps all the time, and has extremely slow movements.
1200:
Client difficult to arouse and desires to stay in bed. Client is unkempt, clothing appears dirty.
0700:
Client who has a history of bipolar disorder was admitted earlier today with agitation, pressured speech, flight of ideas, and sleeping less than 3 hr per night.
1000:
Lithium level 0.7 mEq/L (0.8 to 1.2 mEq/L)
A charge nurse on a mental health unit is receiving a change of shift report for a group of clients.
Complete the following sentence by using the lists of options.
The nurse should first collect data from
Explanation
Client 1 (First Priority):
- Experiencing command hallucinations: Command hallucinations are auditory hallucinations that instruct the client to harm themselves or others, posing an immediate safety concern.
- Potential risk of self-harm: Persecutory delusions and statements indicating "the agents are watching" suggest escalating paranoia, increasing the risk of dangerous behaviors or impulsive self-protective actions. Immediate intervention is essential to prevent harm.
Client 2 (Lower Priority):
- Stopped taking medication: Non-compliance with medication has led to severe depressive symptoms, including isolation, withdrawal, and psychomotor retardation.
- Becoming isolated and withdrawn: While concerning, the risk is lower than active command hallucinations, making this a lower priority for immediate assessment. However, this client requires evaluation soon after Client 1.
Client 3 (Lowest Priority):
- Low lithium level (0.7 mEq/L): This level is slightly below the therapeutic range (0.8 to 1.2 mEq/L) but not critically dangerous.
- Increased risk of agitation and instability: The symptoms of agitation and poor sleep are concerning, but immediate safety threats are less imminent compared to command hallucinations.
A nurse is reinforcing teaching about torts with a newly licensed nurse. The nurse should include which of the following as an example of negligence?
A nurse is discussing conflict resolution with a group of assistive personnel. Which of the following information should the nurse include in the discussion?
A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client's room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?
A nurse on a medical-surgical unit is assisting in providing care for a client. The client's partner asks the nurse about the client's laboratory results. Which of the following actions should the nurse take?
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