a nurse is caring for a client who has schizophrenia and is experiencing delusions which of the following interventions should the nurse implement
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

Correct answer: C

Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.

2. A nurse is teaching a client who has chronic kidney disease about managing protein intake. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D: "You should limit your intake of high-protein foods." Clients with chronic kidney disease should reduce their intake of high-protein foods to lessen the workload on the kidneys and prevent further kidney damage. Choices A, B, and C are incorrect because increasing intake of either plant-based or animal protein or high-protein foods can exacerbate kidney issues in individuals with chronic kidney disease.

3. What is the best method to assess for fluid overload in patients with heart failure?

Correct answer: A

Rationale: The correct answer is A: Monitor daily weight. Daily weight monitoring is the most accurate method to assess fluid overload in patients with heart failure. Changes in weight can indicate fluid retention before visible signs like jugular vein distention or pitting edema appear. Checking for jugular vein distention (choice B) is helpful but may not be as sensitive as daily weight monitoring. Pitting edema (choice C) and fluid retention (choice D) are signs of fluid overload, but daily weight monitoring is a more proactive approach to detect changes early.

4. A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: Corrected Rationale: The correct answer is A, left upper quadrant pain. In acute pancreatitis, inflammation of the pancreas commonly causes pain in the left upper quadrant of the abdomen. This pain can be severe and radiate to the back. Periumbilical pain (choice B) is more indicative of acute appendicitis. Rebound tenderness (choice C) is associated with peritoneal inflammation, not specifically pancreatitis. Flank pain (choice D) is more characteristic of conditions involving the kidneys or ureters, such as renal colic.

5. What is the most appropriate method to assess a patient's level of consciousness?

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

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