a young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision she states she is very angry at
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Nursing Elites

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ATI Adult Medical Surgical

1. A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?

Correct answer: C

Rationale: Validating the client's feelings can help her express and manage her emotions effectively.

2. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?

Correct answer: C

Rationale: In children, ringing in the ears (tinnitus) can be a sign of aspirin toxicity. Aspirin toxicity can be particularly concerning in children and can lead to serious complications. Therefore, it is crucial for the nurse to prioritize monitoring for signs of aspirin toxicity, such as tinnitus, and promptly notify the healthcare provider if such symptoms occur.

3. A client with a newly created ileostomy has not had ostomy output for the past 12 hours and reports worsening nausea. What is the nurse's priority action?

Correct answer: B

Rationale: The nurse's priority action in this situation is to report signs and symptoms of possible obstruction to the healthcare provider. Lack of ostomy output and worsening nausea can indicate a potential obstruction, which requires immediate attention and intervention to prevent complications.

4. The client with newly diagnosed hypertension is being taught about lifestyle modifications. Which recommendation should be made?

Correct answer: C

Rationale: Engaging in at least 150 minutes of moderate exercise per week is a key lifestyle modification recommended for individuals with hypertension. Regular exercise helps manage blood pressure, improve cardiovascular health, and overall well-being. It is important for the client to adopt a healthy lifestyle to control hypertension and reduce the risk of complications.

5. The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?

Correct answer: C

Rationale: To prevent autonomic dysreflexia in clients with spinal cord injuries, it is crucial to ensure the client's bladder is emptied regularly. Bladder distention is a common trigger for autonomic dysreflexia in these clients. Keeping the bladder empty helps prevent the complications associated with autonomic dysreflexia, such as dangerously high blood pressure. Choices A, B, and D are incorrect. Restricting fluid intake can lead to dehydration, keeping the room warm is not directly related to preventing autonomic dysreflexia, and limiting high-fiber foods is not a primary intervention for this condition.

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