a client with a history of substance abuse is admitted for detoxification which intervention is most important during the initial assessment
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?

Correct answer: C

Rationale: Assessing the client's physical health status is the most critical intervention during the initial assessment of a client with a history of substance abuse admitted for detoxification. This evaluation helps identify and address any immediate health risks, such as withdrawal symptoms or medical complications, to ensure the client's safety and well-being during the detoxification process. Option A, obtaining a detailed substance use history, is important but not the most critical initially. Option B, establishing a trusting nurse-client relationship, is important but assessing physical health takes precedence. Option D, determining the client's readiness for change, is valuable but assessing physical health for immediate risks is the priority.

2. A patient with schizophrenia is prescribed olanzapine. What is an important side effect for the healthcare provider to monitor?

Correct answer: B

Rationale: The correct answer is B: Weight gain. Olanzapine, an atypical antipsychotic, is known to cause significant weight gain and metabolic syndrome. It is crucial for healthcare providers to closely monitor patients for these side effects to prevent complications and provide appropriate interventions.

3. What action should the nurse take for a patient admitted with diabetic ketoacidosis exhibiting rapid, deep respirations?

Correct answer: C

Rationale: The correct action for a patient with diabetic ketoacidosis and rapid, deep (Kussmaul) respirations is to administer a normal saline bolus and insulin. The rapid, deep respirations indicate a metabolic acidosis, which requires correction with a saline bolus to prevent hypovolemia and insulin to facilitate glucose re-entry into cells. Oxygen therapy is not necessary since the increased respiratory rate is compensatory and not due to hypoxemia. Encouraging relaxation techniques or administering lorazepam are inappropriate as they can worsen the acidosis by suppressing the compensatory respiratory effort.

4. A patient is admitted with a diagnosis of myasthenia gravis. What symptom should the nurse expect to find during the assessment?

Correct answer: B

Rationale: Myasthenia gravis is a neuromuscular disorder characterized by muscle weakness and fatigue, especially in the voluntary muscles. Patients with myasthenia gravis commonly experience weakness in muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. This weakness typically worsens with activity and improves with rest. Joint pain, loss of sensation, and severe headaches are not typical symptoms of myasthenia gravis. Therefore, the correct answer is muscle weakness (choice B) as it aligns with the characteristic symptom of myasthenia gravis.

5. A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?

Correct answer: A

Rationale: The correct instruction for a client prescribed digoxin is to take their pulse before each dose and hold the medication if the pulse is below 60 beats per minute. This is crucial to prevent digoxin toxicity, as digoxin can cause adverse effects when the pulse rate is too low. Monitoring the pulse regularly ensures safety and appropriate management of the medication.

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