a nurse is caring for a client who is in a seclusion room following violent behavior the client continues to display aggressive behavior which of the
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

1. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?

Correct answer: A

Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.

2. Which of the following interventions promotes patient safety?

Correct answer: D

Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient’s ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.

3. Which of the following parameters should be checked when assessing respirations?

Correct answer: D

Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.

4. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Correct answer: A

Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.

5. What do high-pitched gurgles heard over the right lower quadrant indicate?

Correct answer: C

Rationale: High-pitched gurgles heard over the right lower quadrant indicate normal bowel sounds. Bowel sounds can vary in pitch, and high-pitched gurgles are considered normal and indicate the presence of active peristalsis in the intestines.

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