ATI PN Management
A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following
client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations
• Command hallucinations involve hearing "voices"...
ati pn management a nurse in an outpatient clinic is caring for a client who has schizophrenia for which of the following client actions should the nurse recommend transfer to an acute care facility
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ATI PN Management
A nurse in an outpatient clinic is caring for a client who has schizophrenia. For which of the following
client actions should the nurse recommend transfer to an acute care facility?
The client develops command hallucinations
• Command hallucinations involve hearing "voices" that direct the client to take specific actions. These
actions can be directed at causing self-harm or injury to others. To provide for safety of the client and
others, the nurse should recommend that the client be transferred to an acute care facility.
A nurse is using a critical pathway while providing care to a client who is 3 days postoperative. Which of
the following events should the nurse document as a variance?
The client has a circular area of nonblanchable redness on her left heel
• A variance occurs when expected outcomes of the critical pathway are not met. The nurse should
document that the client has a circular area of nonblanchable redness on her left heel as a variance
because this indicates the initial stage of a pressure ulcer and is not an expected outcome.
A nurse is preparing to reinforce discharge teaching with a client who does not speak the same language
as the nurse. Which of the following actions should the nurse plan to take?
• Select an interpreter who is the same gender as the client.
Ensure interpreters provided by the facility have knowledge of medical terminology.
Choose an interpreter from the same ethnic background as the client.
A charge nurse is asked by two staff nurses to assist in resolving a conflict about holiday scheduling.
Which of the following actions should the charge nurse take?
Encourage each staff nurse to give up something as part of the negotiation.
• The charge nurse should encourage each staff nurse to give up something as part of the negotiation
so that a compromise can be reached that is a win-win situation for each party.
A nurse overhears two assistive personnel discussing the details of a clients diagnosis and treatment plan
int the hospital cafeteria. Which of the following actions should the nurse take?
Inform the APs that the conversation violates the client’s confidentiality
, • The nurse should intervene immediately to stop the conversation and protect the client by informing
the APs that the conversation violates the client's confidentiality.
A nurse in a skilled nursing facility is caring for a group of clients. Which of the following actions
demonstrates the nurses role as client advocate?
• The nurse assists a client in communication end of life decisions to the provider
The nurse acts in the role of client advocate when protecting the client's legal and ethical rights.
A nurse is preparing to document client care in the electronic health record for a client who is
postoperative. Which of the following should the nurse include in the documentation?
• A treatment that was refused by the client.
The nurse should document treatments that were omitted due to client refusal in the medical record.
A home health nurse is reinforcing teaching about the effects of carbon monoxide poisoning. Which of
the following manifestations should the nurse include?
• Headaches
The nurse should reinforce in the teaching that headaches, dizziness, nausea, vomiting, loss of muscle control,
and muscle weakness are manifestations of carbon monoxide poisoning.
A nurse in a long-term care facility enters a client's room and finds the client lying on the floor. Which of
the following actions should the nurse take first?
• Check the client for injuries.
When using the nursing process, the nurse should identify that the priority action is to collect data from the
client. Therefore, the first action the nurse should take is to check the client for injury.
A charge nurse is a member of the resource management team for a skilled care facility. Which of the
following actions should the charge nurse implement to ensure the facility is providing cost-effective
wound care for clients?
• Develop a spreadsheet to prepare a budget for wound care supplies
The nurse should use a spreadsheet to manage numerical data for the preparation of a budget. The use of a
spreadsheet allows the nurse to analyze this data to ensure that cost-effective care is provided to clients.
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