a nurse is caring for a client who reports difficulty falling asleep which of the following recommendations should the nurse make
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Nursing Elites

ATI RN

ATI Proctored Leadership Exam

1. A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

Correct answer: C

Rationale: The correct answer is C: "Maintain a consistent time to wake up each day." Establishing a regular wake-up time helps regulate the body's internal clock and promotes better sleep patterns. Watching television in bed (Choice A) can actually hinder sleep due to the light emitted by screens affecting melatonin production. Drinking beverages with caffeine like hot cocoa (Choice B) close to bedtime can interfere with falling asleep. Exercising vigorously right before bed (Choice D) can increase alertness and make it harder to fall asleep.

2. What is the main purpose of a healthcare proxy?

Correct answer: B

Rationale: The main purpose of a healthcare proxy is to make medical decisions on behalf of the patient when they are unable to do so. Choice A is incorrect as managing financial affairs is typically handled by a power of attorney for finances. Choice C is incorrect as a healthcare proxy is not meant to provide legal representation. Choice D is incorrect as overseeing patient discharge planning is a responsibility of healthcare providers, not a healthcare proxy.

3. The staff nurse delegates AM care for two patients to the UAP (Unlicensed Assistive Person). What principle of delegation is the nurse following?

Correct answer: D

Rationale: The correct answer is D: 'You can delegate only those tasks.' Delegation in nursing involves transferring responsibility for the performance of a task while retaining accountability for the outcome. The principle of delegation does not require a situation with clearly defined superiors (choice A). Delegation can exist not only with a subordinate but also with colleagues or other healthcare team members (choice B). Delegation is not exclusive to nurses and is a tool used by various healthcare professionals (choice C). Therefore, the best choice is D as it accurately reflects the principle of delegation in nursing.

4. What is the primary focus of health promotion activities?

Correct answer: C

Rationale: The correct answer is C: 'To prevent the onset of disease.' Health promotion activities aim to prevent diseases before they occur by promoting healthy behaviors, lifestyles, and environments. Choice A, 'To manage chronic diseases,' is incorrect as health promotion focuses on prevention rather than management. Choice B, 'To educate patients about their health,' is important but not the primary focus of health promotion. Choice D, 'To identify and treat diseases early,' is related to early detection and treatment, which is different from the primary goal of health promotion.

5. During a physical assessment of adult clients, which of the following techniques should the nurse use?

Correct answer: B

Rationale: When performing a physical assessment, it is essential to palpate the client's abdomen before auscultating bowel sounds. This sequence helps prevent altering bowel sound results due to the pressure applied during palpation. Choice A is incorrect because the FLACC pain rating scale is typically used for nonverbal or pediatric clients, not adults. Choice C is incorrect because the bladder of the blood pressure cuff should surround about 80% of the client's arm circumference, not the bladder of the cuff itself. Choice D is incorrect because to obtain an apical heart rate, auscultation should be done at the fifth intercostal space at the midclavicular line, not at the third intercostal space to the left of the sternum.

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