a client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tylenol tabl
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse’s first priority?

Correct answer: D

Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.

2. A patient with a history of gout should avoid which type of food?

Correct answer: A

Rationale: A patient with a history of gout should avoid foods high in purines, which can exacerbate gout attacks. Red meat is particularly high in purines, so it is the type of food that should be avoided. Chicken and fish are lower in purines compared to red meat, making them better choices for individuals with gout. Dairy products are generally not associated with triggering gout attacks, so they can be consumed in moderation by patients with gout.

3. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison’s disease?

Correct answer: A

Rationale: The correct answer is A because tapering glucocorticoids is crucial to prevent adrenal insufficiency, which can occur if the medication is stopped abruptly. Choice B is incorrect as it refers to dose adjustments during stress or infection, not discontinuation. Choice C is incorrect because it does not specifically address the issue of stopping the medication. Choice D is not directly related to the management of glucocorticoid therapy for Addison’s disease.

4. What causes hepatic encephalopathy?

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.

5. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires immediate intervention?

Correct answer: D

Rationale: Choice D is the correct answer because a swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency. Testicular torsion occurs when the spermatic cord twists, cutting off the blood supply to the testicle. This condition requires immediate intervention to prevent testicular damage. Choices A, B, and C do not present findings that suggest a surgical emergency requiring immediate intervention.

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