the nurse is preparing a care plan for a patient who is immobile which psychosocial aspect will the nurse assess for
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?

Correct answer: C

Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.

2. Which goal is most appropriate for a patient who has had a total hip replacement?

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

3. Which of the following is a common manifestation of opioid withdrawal?

Correct answer: B

Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.

4. A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

Correct answer: D

Rationale: The correct answer is D because a client with a fractured femur and sudden chest pain may be experiencing a pulmonary embolism, which requires immediate assessment. Choice A is incorrect because although severe pain is present, it is more indicative of musculoskeletal issues related to urolithiasis rather than a life-threatening condition. Choice B, related to acute cholecystitis, is less urgent than choice D as the pain radiating to the right shoulder is a common symptom but does not indicate an immediate life-threatening situation. Choice C, regarding a client post-total knee arthroplasty with a pain level of 8, is important but not as urgent as a potential pulmonary embolism in choice D.

5. A patient with a history of hypertension is admitted for chest pain. What is the most appropriate action for the nurse to take first?

Correct answer: B

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient presenting with chest pain as it helps dilate blood vessels, reduce chest pain, and improve oxygen supply to the heart. Obtaining a detailed medical history, conducting an ECG, or administering morphine sulfate are important steps in the assessment and treatment process but are secondary to the immediate need to address chest pain and potential cardiac ischemia.

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