ATI practice test End of L
Which is the highest priority nursing diagnosis for a patient with a spinal cord injury and no pain sensation below the waist?
Potential for injury related to lack of sensation and protective reflexes
A nurse is observing an assistive personnel performing postmortem care for a client who is Muslim. Which of the following actions should prompt the nurse to intervene?
Prepares to cleanse the body
A postoperative client asks the nurse how the prescribed ibuprofen will control the incisional pain. The nurse will teach the client that ibuprofen interferes with the pain process by decreasing which of the following physiological responses?
Production of pain sensitizing chemicals
When doing a pain assessment for a client who has been admitted with metastatic breast cancer, which question asked by the nurse will give the client's pain?
"How would you describe your pain?"
A nurse is caring for a client who has cancer and is receiving palliative care. Which of the following statements by the client indicates they understand this type of treatment?
"I am hoping this will limit my discomfort"
A nurse on the hospice unit is caring for a newly-admitted client. Which of the following client statements should the nurse report to the provider?
"I plan to take an antiaging supplement to prolong my life"
A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?
"I should except the hospice team to help me manage my dyspnea."
A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient-controlled analgesia (PCA) infusion device. Which of the following client statements indicates an understanding of the teaching?
"I should tell the nurse if I can't control my pain with this device."
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. which of the following client statements indicates an understanding of pain control?
"I will call for pain medication before the previous dose wears off"
A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
"It's unfortunate that I have to be in the hospital for this treatment"
A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. Which of the following instructions should the nurse include in the teaching?
"use the pain scale to determine if you need to self-administer."
a nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. the client states, "I want to go home; my husband is waiting for me to cook dinner." which of the following responses by the nurse is appropriate?
"Tell me what you like to cook for dinner"
A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?
"Use contraception while taking this medication"
A nurse is providing palliative care to a client whose partner asks why music therapy might help her. Which of the following responses should the nurse make? (select all that apply) -"music therapy will increase her basal metabolic rate" -"music therapy can help her verbally express emotions" -"music therapy will improve her appetite and decrease the nausea" -"music therapy works as a distraction and can help alleviate her pain" -"music therapy can help facilitate movement in some clients who have mobility limitations"
-"music therapy can help her verbally express emotions" -"music therapy works as a distraction and can help alleviate her pain" -"music therapy can help facilitate movement in some clients who have mobility limitations"
A nurse is providing postmortem care for an adult client which of the following actions should the nurse take? (Select all that apply? -Place the client lying flat on bed -Determine whether the client will have an autopsy -Cover the body with a clean sheet and place the arms outside of the sheet -If the client had significant trauma, discourage family and friends from viewing the body -Give the client's personal belongings to the family
-Determine whether the client will have an autopsy -Cover the body with a clean sheet and place the arms outside of the sheet -Give the client's personal belongings to the family
A nurse is providing postmortem care for a client. Identify the sequence of steps the nurse should follow. -Attach identification tags to the body -Verify the client organ and tissue donation status -Make sure the provider has certified the client's death -Cleanse the body while adhering to body-fluid precautions -Remove medical equipment from the client
-Make sure client is certified died -Verify the client organ and tissue donation status -Remove medical equipment -Cleanse the body -Attach identification tags to the body
A hospice nurse is reviewing the prescriptions for a client who is receiving palliative care. Which of the following prescriptions should the nurse expect? (select all that apply) -Provide skincare with moisture barrier cream -Administer artificial tears PRN -Obtain vital signs every 2 hrs -Perform mouth care every hour -Administer oxygen 2 L/min via nasal cannula
-Provide skincare with moisture barrier cream -Administer artificial tears PRN -Perform mouth care every hour -Administer oxygen 2 L/min via nasal cannula
A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing and restless. Which of the following findings should the nurse identify as indicating a therapeutic response? (Select all that apply) -The shoulders droop -The facial muscles relax -The respiratory rate increases -The pulse is within the expected range -The client draws his legs up into a fetal position
-The shoulders droop -The facial muscles relax -The pulse is within the expected range **
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
A client who has terminal cancer and needs assistance with pain management
The nurse is caring for a client who is taking an opioid for postoperative pain. Which of the following interventions should the nurse include in the clients plan of care to manage possible adverse effects of opioids?
Administer the prescribed stool softener OD.
The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a trip across the country "to settle some issues with my sisters and brothers." Which of the responses should the nurse recognize that the client is manifesting?
Anxiety about unfinished business
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?
Ask the client to rate her pain on a scale from 0 to 10
A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?
Asking the client to rate the pain
The nurse is caring for a terminally ill client who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which of the following terms should the nurse use to document this findings?
Cheyne-Stokes respirations
A client who uses fentanyl patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0-10) and requests "something for pain that will work quickly." Which of the following types of pain is the most appropriate for the nurse to document for this client?
Breakthrough pain
A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Strokes respirations?
Breathing ranging from very deep to very shallow with periods of apnea
which of the following actions should the nurse consider when developing the plan of care for an older adult who is hospitalized for an acute illness?
Consider preadmission functional abilities when setting client goals
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
Determine the location of the pain
A nurse is caring for a client who has metastatic cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?
Discuss initiating hospice care with the client and family
a nurse is teaching a client who has fibromyalgia about measures to reduce the occurrence of symptoms? which of the following interventions should the nurse include in the teaching?
Establish a regular sleep pattern
Which medication order will provide the most consistent control of patient's chronic pain?
Fentanyl transdermal patch 25 mcg
Findings from a health history indicate that the client takes daily supplements of the antioxidants beta carotene, vitamin C, and vitamin E. This health practice reflects which of the following theories of biological aging?
Free radials
A client with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. Which of the following reasons provide the basis for the nurse's response in relation to the effectiveness of these strategies?
Impact the cognitive and affective components of pain
A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?
Increase heart rate
The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the client about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work but otherwise things are fine." Which of the following nursing diagnoses is appropriate?
Ineffective denial related to threat of unpleasant reality
Which is an example of nociceptive pain?
Pain from rheumatiod arthritis joint damage
The nurse is planning care for an alert and active older-adult client who takes multiple medications for chronic cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate?
Risk for injury as evidenced by exposure to toxic chemical (drug-drug interactions)
The nurse is assessing the nutritional status of an older-adult client using the SCALES acronym. Which of the following should the nurse assess when completing the "S"?
Sadness or mood changes
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
Self-report of pain
Why is acute pain particularly dangerous for a patient having a heart attack?
Stimulation of the sympathetic nervous system will increase cardiac workload
A hospice nurse is caring for a client who has terminal cancer and take PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?
The client developed a tolerance to the medication
The nurse is caring for a young adult who is dying after an automobile accident. The family members want to donate the client's organs and ask the nurse how the decision when death has occurred is made. Which of the family is made. Which of the following is the basis for the family in this situation?
The client is unconscious with no brain stem activity
The nurse is caring for a patient who continues to have server pain at the site of a fracture long after it healed. The patient's physicians can find no rationale for the pain. What us most likely cause of the patient's discomfort?
The patient has developed a complex regional pain syndrome.
The nurse is providing hospice care to a client who is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the following is the basis for the nurses' response about these symptoms?
They are a normal response decrease
Which of the following actions would enable the nurse to obtain the most complete info when doing an assessment with an older-adult client?
Use a geriatric assessment instrument to evaluate the client
a nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the include in the teaching?
you may experience drowsiness while taking this medication
