Comprehensive ATI Practice A (Study) QUESTIONS WITH COMPLETE SOLUTIONS

A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? - Displacement -Regression -Suppression -Sublimation Correct Answer: Sublimation - The client is exhibiting behaviors consisting with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? -Check the client's temp q2hr -Initiate fall precautions for the client -Monitor the client's urine for discoloratio -Limit the client's fluid intake to 1 L per day Correct Answer: Initiate fall precautions for the client - The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy A nurse on a med-surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? -The client's partner tells the nurse that the client understands the procedure -The nurse locates the provider's prescription for the surgical procedure -The nurse witnesses the provider's explanation of the procedure -The client is able to accurately describe the upcoming procedure Correct Answer: The client is able to accurately describe the upcoming procedure - The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent form An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? -Uses a draw sheet to move the client to the left side of the bed -Raises the total height of the bed to waist level -Places a pillow under the client's right arm -Lowers the side rails on the left side of