ATI Predictor exam
A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is
... [Show More] associated with this diagnosis?
A. Increased appetite
B. Elevated Temperature
C. Bradycardia
D. Drowsiness - correct answer Elevated Temperature
Rationale: The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.
A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?
A. "I know this must be difficult, but your mother will calm down soon."
B. "Lets discuss some strategies you can use when this happens again."
C. Individuals near death are ready to let go toward the end."
D. "Have you determined why she is crying and saying she is ready to die?" - correct answer " Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce anxiety and enhance decision making. This response creates a safe environment, fosters trust and respect, and is appropriate.
A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia - correct answer Lethargy
rationale: Lethargy occur [Show Less]