ATI Nursing 130 Exam 2

Correct Answers: 

Ensure privacy and security

Improve safety and quality

Engage clients and families

Coordinate care

Improve population health

Explanation

Ensure privacy and security.

Protecting patient information is a fundamental part of meaningful use. The Health Information Technology for Economic and Clinical Health (HITECH) Act emphasizes safeguarding electronic health records by ensuring compliance with HIPAA regulations.

Improve safety and quality.

EHRs are designed to enhance patient safety by reducing medication errors, improving documentation accuracy, and supporting clinical decision-making. They also promote better adherence to evidence-based guidelines.

Engage clients and families.

One of the key goals of meaningful use is to empower patients by providing them with access to their own health records. EHRs enable patient portals and other tools that encourage active participation in healthcare decisions.

Coordinate care.

EHRs facilitate better communication among healthcare providers, improving transitions of care. By integrating patient data across different providers and specialties, care coordination is enhanced, reducing duplication of services and improving efficiency.

Improve population health.

Meaningful use encourages using EHRs to track and analyze health trends at a community level. This helps with early detection of disease outbreaks, better management of chronic conditions, and public health interventions.

Why the Other Option Is Incorrect:

Share information with other systems.

While interoperability (the ability to share health information across different systems) is an important feature of EHRs, it is not one of the Five Pillars of Meaningful Use. The focus is on improving health outcomes rather than just sharing data.

Summary:

The Five Pillars of Meaningful Use of EHRs include ensuring privacy and security, improving safety and quality, engaging clients and families, coordinating care, and improving population health. These principles support better healthcare delivery and patient outcomes by leveraging technology to enhance efficiency, safety, and communication.

Correct Answer: Clear the area around the child to protect the child from injury.

Explanation

The most important nursing intervention during a grand mal (tonic-clonic) seizure is to ensure the child's safety. Clearing the surrounding area helps prevent injury from hitting objects during uncontrolled movements. If possible, placing a soft object under the child's head can provide additional protection. The nurse should also position the child on their side if possible to maintain an open airway and reduce the risk of aspiration.

Why the Other Options Are Incorrect

Beginning cardiopulmonary resuscitation (CPR)

This is not necessary unless the child stops breathing and has no pulse. During a seizure, breathing may be irregular, but it usually resumes normally once the seizure ends. The focus should be on maintaining airway patency and preventing injury.

Restraining the child to prevent injury is incorrect and dangerous.

Restraints can cause musculoskeletal injury and increase agitation. Instead, the nurse should allow the seizure to run its course while ensuring a safe environment.

Placing a tongue blade over the tongue to prevent aspiration

This is incorrect and unsafe. Forcing an object into the child's mouth can cause airway obstruction, dental injury, or aspiration. The best approach is to turn the child onto their side to allow secretions to drain.

Summary

The priority during a grand mal seizure is to ensure the child’s safety by clearing the surrounding area to prevent injury. The nurse should avoid restraints, never place anything in the child’s mouth, and monitor breathing while positioning the child on their side if possible.

Correct Answer

Ask the family to stay with the patient if possible

Inform the family of the risks associated with side rail use

Discuss alternatives with the family that are appropriate for this patient

Explanation

Ask the family to stay with the patient if possible

Asking the family to stay with the patient if possible provides direct supervision and support, reducing the need for physical restraints like raised side rails. Family members can help reorient the patient and ensure their safety while meeting their emotional needs

Inform the family of the risks associated with side rail use

 Informing the family of the risks associated with side rail use is essential because four raised side rails can increase the risk of falls and injury. Confused and ambulatory patients may attempt to climb over the rails, leading to severe falls. Educating the family about these risks helps them make informed decisions about their loved one’s care.

Discuss alternatives with the family that are appropriate for this patient

Discussing alternatives with the family that are appropriate for this patient ensures that safety measures are individualized and effective. Alternatives may include using a low bed, providing frequent monitoring, using bed alarms, or arranging for a sitter to stay with the patient. Collaboration with the family fosters trust and ensures patient-centered care.

Why the Other Options Are Incorrect

Contact the nursing supervisor.

Contacting the nursing supervisor is unnecessary at this stage. The nurse has the responsibility and ability to educate the family and implement appropriate safety measures before escalating the issue.

Restrict the family's visiting privileges.

Restricting the family's visiting privileges is inappropriate and does not address the safety concern. Family involvement is beneficial in patient care, and limiting visits may increase patient agitation and confusion.

Thank the family for being conscientious and put the four rails up.

 Thanking the family and putting the four side rails up disregards the risks associated with this action. While the family’s concerns are valid, blindly following their request without considering patient safety contradicts best nursing practices

Summary

The best approach is to educate the family about the dangers of four raised side rails, involve them in discussions about safer alternatives, and encourage their presence if possible. This ensures patient safety while maintaining a collaborative and supportive relationship with the family.

Correct Answer: Hopelessness

Explanation:

The patient’s behaviors — such as appearing quiet and withdrawn, expressing belief that the treatments will not make any difference, and missing chemotherapy sessions — are indicative of hopelessness. Hopelessness is a nursing diagnosis that can be made when a patient expresses a lack of belief in the possibility of improvement or positive change and exhibits behaviors such as withdrawal, lack of motivation, and disengagement from treatment. These signs suggest that the patient is struggling with a perceived inability to influence her situation, a hallmark of hopelessness.

Why the Other Options Are Less Effective:

Anxiety

While the patient may feel anxious due to her diagnosis and treatment, the primary symptoms observed in this case are more aligned with hopelessness than anxiety. Anxiety typically involves excessive worry, nervousness, and fear of future events. The patient's quietness, lack of interest in progress, and missed treatments are more consistent with hopelessness than anxiety.

 Spiritual distress

Although cancer treatment can sometimes provoke spiritual questions or concerns, there is no clear evidence in this case of the patient experiencing a crisis related to her spirituality. Spiritual distress would be more likely if the patient expressed questions about the meaning of life, feeling disconnected from spiritual beliefs, or experiencing a loss of faith. The symptoms described here are more suggestive of hopelessness rather than spiritual distress.

Complicated grieving

The patient is undergoing treatment for cancer, which is likely related to the active phase of illness, not necessarily to grief. Complicated grieving typically refers to intense sorrow and mourning following a loss (e.g., loss of a loved one) that persists and interferes with functioning. This patient’s behaviors suggest hopelessness about her prognosis rather than grieving the loss of something or someone.

Summary:

The most appropriate nursing diagnosis for this patient is hopelessness. The behaviors and statements observed are consistent with feelings of hopelessness, which may manifest in withdrawal, lack of interest in treatment, and a belief that improvement is impossible. The other options — anxiety, spiritual distress, and complicated grieving — do not align as closely with the observed behaviors.

Correct Answer: Provide bedtime rituals.

Explanation

Providing bedtime rituals helps promote sleep by maintaining a sense of familiarity and comfort for the toddler. Hospitalization can be stressful, and familiar routines, such as reading a bedtime story, singing a lullaby, or allowing the child to have a favorite blanket or stuffed animal, can provide reassurance. These rituals signal to the child that it is time to sleep, helping them feel safe and secure even in an unfamiliar environment. Consistent bedtime routines have been shown to improve sleep quality in young children.

Why the Other Options Are Wrong:

Turn off the room light

While a dark environment may help older children and adults sleep, toddlers often feel scared in complete darkness, especially in an unfamiliar hospital setting. A dim nightlight is typically more appropriate, as it provides comfort while still promoting sleep. Turning off the light completely may increase the toddler’s fear and anxiety, making it harder for them to sleep.

 Encourage play exercises in the evening

Engaging in active play or physical exercise right before bedtime can increase energy levels and make it more difficult for the toddler to fall asleep. While physical activity is important during the day, it should be avoided close to bedtime. Instead, quiet and calming activities should be encouraged before sleep.

Explain the source of the toddler's fears

While acknowledging and addressing a toddler’s fears is important, explaining the source of their fears in detail may not be effective due to their limited cognitive ability to process complex explanations. Instead, the focus should be on providing comfort and reassurance through familiar bedtime rituals rather than an in-depth discussion of fears.

Summary:

Providing bedtime rituals is the best approach to help a hospitalized toddler sleep, as it offers comfort and a sense of normalcy. Turning off the room light completely may increase fear, encouraging play before bedtime can overstimulate the child, and explaining fears may not be developmentally appropriate.

Correct Answer: Since your husband died, what have you been doing in the evening when you feel lonely?

Explanation:

This question addresses the developmental crisis the woman may be facing following a life transition such as the death of a spouse. Developmental crises typically occur during expected life changes, such as the loss of a spouse, retirement, or other significant life transitions, and they can trigger feelings of grief, loneliness, or other emotional responses.

Why the Other Options Are Less Effective:

How is this flood affecting your life?: This question would be more appropriate for a situational crisis, which arises from unexpected events like natural disasters (e.g., a flood). It doesn't align with the assessment of a developmental crisis, which is linked to life changes related to aging or expected milestones.

 How is having diabetes affecting your life?: While diabetes can certainly cause health issues and stress, it isn't necessarily a developmental crisis unless it is part of a larger life transition (e.g., aging, retirement). This question might be more relevant for a health-related crisis but isn't directly related to a developmental crisis.

I know this must be hard for you. Let me tell you what might help.: This response is less effective because it assumes the woman's feelings and offers advice before asking her to express her own experiences. It’s important to first listen and gather information before offering solutions.

Summary:

The question "Since your husband died, what have you been doing in the evening when you feel lonely?" effectively invites the older woman to reflect on her feelings of loneliness after the death of her spouse, a typical developmental crisis related to aging and life changes. It fosters a deeper conversation about coping with a life transition, allowing the nurse to assess and support her needs during this time.

Correct Answer: Self-efficacy

Explanation:

Self-efficacy refers to a person's belief in their ability to successfully perform tasks and manage challenges. In this scenario, the client demonstrates self-efficacy by feeling confident and pleased with their postoperative progress, indicating they believe in their ability to carry out the prescribed care and exercises effectively. The client is actively engaging in their recovery and is taking responsibility for their healing process, which reflects high self-efficacy.

Why the Other Options Are Less Appropriate:

Emotional intelligence: Emotional intelligence involves recognizing, understanding, and managing one’s emotions, as well as empathizing with others' emotions. While emotional intelligence is important in caregiving and relationships, it is not directly demonstrated in this scenario, as the client is expressing confidence in their recovery rather than managing emotions.

Self-awareness: Self-awareness involves recognizing and understanding one's emotions, strengths, weaknesses, and how these factors affect behavior. While the client may have some degree of self-awareness in their recovery, the focus here is on the client’s confidence in their ability to complete tasks, which is more aligned with self-efficacy.

Generativity: Generativity refers to the concern for guiding and nurturing the next generation, which typically manifests in mid-life. This concept is more relevant to parenting, mentoring, and contributing to the well-being of others. It does not directly apply to the client’s experience of postoperative recovery.

Summary:

The client's confidence in their recovery process and ability to manage their postoperative care and exercises reflects self-efficacy, as they believe in their ability to handle challenges and succeed in their recovery.

Correct Answer: A nurse can only access the records of clients they are actively caring for.

Explanation

Nurses are allowed to access a client's medical records only if they are actively involved in the care of that client. This is a key principle of patient confidentiality and the Health Insurance Portability and Accountability Act (HIPAA), which protects the privacy and security of health information. Accessing records for any other reason, such as curiosity or for clients not under their care, is prohibited.

Why the Other Options Are Incorrect

A nurse can share information about a client who has a similar diagnosis.

This is incorrect because sharing client information is not allowed based solely on similar diagnoses. Patient information is confidential and should not be shared without the client's consent or a legitimate need to know within the healthcare team involved in their care.

A nurse can only share information from the client's medical record with immediate family members.

This is incorrect because information can only be shared with family members if the client has provided consent. Nurses cannot disclose personal health information to family members without the client’s permission, unless there is a legal exception (e.g., in cases where the client is incapacitated).

A nurse can access records of any client in the healthcare facility, as long as the information is not shared.

This is incorrect because accessing records without a legitimate reason (i.e., actively caring for the patient) violates HIPAA regulations. Accessing records just because they are available is considered a breach of confidentiality, regardless of whether the information is shared.

Summary

The correct answer is a nurse can only access the records of clients they are actively caring for because a nurse can only access the medical records of clients they are actively caring for. The other options are incorrect because sharing information about clients without proper consent, accessing records without a legitimate need, or sharing with family members without consent are violations of patient confidentiality and HIPAA regulations.

Correct Answer: Low health literacy leads to increased use of emergency services

Explanation of the Correct Answer

Health literacy refers to a person's ability to obtain, process, and understand basic health information to make appropriate health decisions. Clients with low health literacy often struggle to manage chronic conditions, understand medication instructions, and navigate the healthcare system. As a result, they are more likely to use emergency services for conditions that could have been managed through primary or preventive care. Increased reliance on emergency services can lead to higher healthcare costs and worse health outcomes.

Explanation

Clients who have low health literacy have lower mortality rates than others.

This statement is incorrect because research indicates that low health literacy is associated with higher mortality rates, not lower. Individuals with poor health literacy often have difficulty understanding medical instructions, managing chronic diseases, and recognizing serious symptoms, all of which contribute to poorer health outcomes and increased mortality.

Low health literacy leads to an increase in preventive services.

This is incorrect because individuals with low health literacy are less likely to use preventive services. They may not understand the importance of routine screenings, vaccinations, or early intervention, which can lead to delays in care and progression of preventable diseases.

Clients who have low health literacy tend to have greater availability of care.

This statement is incorrect because low health literacy is often linked to decreased access to care. Individuals with low health literacy may have difficulty finding healthcare providers, understanding insurance policies, and following up on medical referrals, all of which limit their ability to access appropriate healthcare services.

Summary

The correct answer is Low health literacy leads to increased use of emergency services because low health literacy leads to increased use of emergency services due to difficulty managing health conditions and accessing preventive care. The other options are incorrect because low health literacy is associated with higher mortality rates, decreased use of preventive services, and reduced access to healthcare, rather than greater availability of care.