ATI Practice Exam 3

a nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. which of the following clients is at risk for developing hep c?

A client who has multiple tattoos Rationale: Hepatitis C is transmitted via blood-to-blood contact. The nurse should recognize that improperly maintained tattoo equipment may aid in transmission and could increase the client's risk for contracting hepatitis C

a nurse is caring for a client who has HIV. which of the following lab values in the nurse's priority?

CD4-T-cell count 180 cells/mm3 Rationale: A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.

a nurse is setting goals for a client who has AIDS and is at the end of life. which of the following are realistic goals?

The client will receive medication to minimize episodes of breakthrough pain. Rationale: The client should receive medication to minimize episodes of breakthrough pain as a goal for the end of life care.

a nurse is presenting a community based program about HIV and AIDS. a client asks the nurse to describe the initial symptoms experienced with HIV infections. which of the following cm should the nurse include in the explanation of initial symptoms?

Flu-like symptoms and night sweats Rationale: The nurse should explain that the initial symptoms may include flu-like symptoms and night sweats in category A of HIV infection.

A nurse remains w/a client to observe for any adverse rxns after initiating a transfusion of PRBCs. the client becomes apprehensive and tachycardic, reporting HA and low back pain. the nurse should recognize that these findings indicate which of the following transfusion rxns?

Hemolytic Rationale: In addition to tachycardia, headache, and low back pain, a hemolytic reaction can also cause fever, chills, hypotension, possible chest pain, and hemoglobinuria.

a nurse is caring for a client who has T4 SCI. which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended. Rationale: Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

a nurse is caring for a client who has had a SCI at the level of the T2-T3 vertebrae. when planning care, the nurse should anticipate which of the following types of disability?

Paraplegia Rationale: Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1

a nurse is teaching a client who has hep a about preventing transmission of the virus. which of the following strategies should the nurse include in the teaching?

Practice effective hand hygiene. Rationale: Effective hand hygiene—along with immunization, sewer sanitation, and a safe water supply—are the most effective strategies for preventing the transmission of hepatitis A

after mr. H passed away from cancer, his son reflected years later and wished that he and his father talked more about their lives together. this reflection demonstrates that mr. H's son missed which of the 5 stages of GOODBYE

Stage IV: Resolution Rationale: As they enter Stage 4, family members often find themselves having more memories—both good and bad—of past experiences which usually reflect relationships with the patient, these important memories are different, typically telling the story of how family members have viewed their place and role in the family. Often they point to unresolved issues. Some of these memories may evoke feelings of joy or nostalgia; others, however, may evoke anger, jealousy, or envy. Others still cause feelings of pride or, alternatively, of shame and embarrassment. https://www.helpguide.org/harvard/saying-goodbye.htm

a nurse is assessing for a client for a suspected anaphyactic rxn following a ct scan w/contrast media. for which of the following client findings should the nurse intervene first?

Stridor Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance

a nurse is caring for a 48 y.o. client who is grieving following the death of her husband 7m ago. the client reports that she has lost 30lbs and is having difficulty sleeping. which of the following factors indicate the client is experiencing maladaptive grieving?

The client's husband died seven months ago. Rationale: One of the defining factors of maladaptive grieving is grief that lasts 6 months or longer after the loss

a nurse is assessing a client who is experiencing chronic stress. which of the following findings should the nurse expect?

Viral infection Rationale: The nurse should expect to find the client with a decreased immune response, which leads to viral or bacterial infections in response to chronic stress.

the nurse knows that food rich in K+ should be restricted in the pt with acute poststreptococcal glomerulonephritis during which stage of the disease?

during the oliguric stage

the pt w/pancreatitis complains of circumoral tingling, a constricted feeling in the throat, and spasms in the fingers and toes. the nurse knows that these findings are consistent w/which of the following electrolyte imbalances which is an important complication in the pt w/acute pancreatitis

hypocalcemia

a nurse is planning care for a client who has acute poststrep glomerulonephritis. which of the following interventions should the nurse include in the plan?

monitor BP every 4-6 hrs

a nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T count. the nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Candidiasis Rationale: Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older adults, and clients whose immune systems have been compromised by illness, such as AIDS, or medications

a nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. the nurse should document that the client has which of the following respiratory alternations?

Cheyne-Stokes respirations Rationale: Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death)