ATI Comprehensive Predictor A

ATI Comprehensive Predictor A 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? Sublimation Rationale: The client is exhibiting behaviors consistent 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? Initiate fall precautions for the client Rationale: 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 is able to accurately describe the upcoming procedure Rationale: 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 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? Places a pillow under the client's right arm. Rationale: The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder. A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Introduce new foods one at a time over 5 to 7 days. A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement? Contact Rationale: The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA. A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first Massage the uterus to expel clots Rationale: Using the EBP approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding. A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? "Secure the retainer clip at the level of your baby's armpits" A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies. "Which of the following actions should the nurse take? (SATA) -Refer the client to a community based social workers -Initiate a consult with a home health care provider -Give the client information about local support groups