the community mental health nurse is planning to visit four clients with schizophrenia today which client should the nurse see first
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Nursing Elites

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ATI Learning System PN Medical Surgical Final Quizlet

1. The community mental health nurse is planning to visit four clients with schizophrenia today. Which client should the nurse see first?

Correct answer: A

Rationale: The mother who took her children from school due to delusions of aliens poses a significant risk to her children and herself. This situation requires immediate attention to ensure the safety and well-being of all involved. Choice B is concerning due to the history of substance abuse, but the immediate risk to life and safety as in Choice A takes precedence. Choice C, although important, does not present an immediate danger as the delusional belief of aliens. Choice D, while emotionally distressing, does not pose an immediate threat as the situation described in Choice A.

2. After performing a paracentesis on a client with ascites, 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?

Correct answer: D

Rationale: Following a paracentesis where a significant amount of fluid is removed, it is crucial to monitor the client's vital signs. This helps in detecting any signs of hypovolemia, such as changes in blood pressure, heart rate, and respiratory rate, which could indicate complications post-procedure. Monitoring the vital signs allows for prompt intervention if there are any deviations from the baseline values.

3. An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report?

Correct answer: B

Rationale: When a client increases their daily doses of acetaminophen for joint pain, it raises concerns about possible liver damage due to acetaminophen overdose. LDH (Lactate Dehydrogenase) levels can indicate liver function, so comparing today's levels with previous ones can help assess for liver damage caused by acetaminophen overuse.

4. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

Correct answer: B

Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.

5. A 65-year-old woman presents with difficulty swallowing, weight loss, and a history of long-standing heartburn. She has been on proton-pump inhibitors for years, but her symptoms have worsened. What is the most likely diagnosis?

Correct answer: B

Rationale: The presentation of difficulty swallowing, weight loss, and worsening symptoms despite long-term use of proton-pump inhibitors raises suspicion for esophageal cancer, especially in a patient with a history of chronic heartburn. Esophageal cancer should be considered in this scenario due to the concerning symptoms and lack of improvement despite appropriate medical management.

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