a nurse is caring for a client who is in the orientation phase of the therapeutic relationship which statement should the nurse make during this phase
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Nursing Elites

ATI RN

ATI Exit Exam 2024

1. A nurse is caring for a client who is in the orientation phase of the therapeutic relationship. Which statement should the nurse make during this phase?

Correct answer: B

Rationale: During the orientation phase of the therapeutic relationship, it is crucial to establish roles. This helps both the client and the nurse understand their responsibilities, boundaries, and expectations within the therapeutic process. Choice A is more focused on the working phase where strategies and interventions are discussed. Choice C is more suitable for the working phase where specific techniques are usually introduced. Choice D is also more relevant to the working phase as it involves discussing practical resources for implementation in daily life.

2. 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.

3. A client is being taught about patient-controlled analgesia (PCA). Which statement should be included in the teaching?

Correct answer: D

Rationale: The correct statement to include in the teaching about PCA is that the client can adjust the amount of pain medication they receive by pushing on the keypad. This empowers the client to control their pain management effectively. Choice A is incorrect because PCA systems are programmed to prevent double dosing when the button is pressed multiple times in quick succession. Choice B is incorrect as continuous PCA infusion aims to maintain a steady plasma medication level. Choice C is incorrect because it is not necessary to push the button before physical activity to ensure maximum pain control; the client should use the PCA as needed for pain relief.

4. A client is being assessed in the PACU. Which of the following findings indicates decreased cardiac output?

Correct answer: B

Rationale: Oliguria is a sign of decreased cardiac output. Decreased cardiac output can lead to poor renal perfusion, resulting in decreased urine output (oliguria). This requires immediate intervention to improve cardiac function and perfusion. Shivering (Choice A) is a response to cold stress and does not directly indicate decreased cardiac output. Bradypnea (Choice C) refers to abnormally slow breathing rate and is more indicative of respiratory issues rather than decreased cardiac output. Constricted pupils (Choice D) are associated with the parasympathetic nervous system response and not directly related to cardiac output.

5. How should a healthcare professional manage a patient with hypertension who is non-compliant with medication?

Correct answer: A

Rationale: Providing education on the importance of medication is crucial in managing hypertension in patients who are non-compliant. By educating the patient about the significance of taking medication as prescribed, the healthcare professional can help improve the patient's understanding and motivation to adhere to the treatment plan. Referring the patient to a specialist (Choice B) may be necessary in some cases but addressing non-compliance should start with education. Discontinuing the medication (Choice C) without addressing the root cause of non-compliance can worsen the patient's condition. Exploring alternative treatment options (Choice D) should come after ensuring the patient understands the importance of the current treatment regimen.

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