Final ATI quiz
A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating which of the following alterations? Cerebellar dysfunction Occipital lobe dysfunction Increased intraocular pressure Macular degeneration
A. Cerebellar dysfunction Cerebellar dysfunction causes a loss of position sense (proprioception), which results in a positive Romberg sign. Incorrect Answers: B. Dysfunction of the occipital lobe causes a loss of vision. C. An increase in intraocular pressure is a manifestation of glaucoma. D. Macular degeneration causes a loss of vision in the center of the visual field due to retinal damage.
A nurse is caring for a client at a college mental health counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms? Projection Dissociation Undoing Compensation
A. Projection The client is using projection when unconsciously transferring unacceptable feelings, thoughts, or traits from oneself onto another person. This response is maladaptive because it prevents the client from accepting responsibility for personal performance in school. Incorrect Answers: B. This client is not using the defense mechanism of dissociation, which results in the client's compartmentalization of undesirable personal attributes. C. This client is not using the defense mechanism of undoing, which involves an attempt to make up for an unacceptable action. D. This client is not using the defense mechanism of compensation, which involves an attempt to focus on a strength to compensate for a perceived weakness.
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client Order pureed foods Make sure feedings are provided at room temperature Offer the client a drink of fluid after every bite
Correct Answer: A. Sit at the bedside while feeding the client The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding. Incorrect Answers: B. Without any mouth or throat injuries that make chewing or swallowing difficult, the client should be served foods of an appropriate variety of textures. Pureed foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth. C. The nurse should ask the client if the food is the correct temperature. D. If the client is unable to communicate, the nurse should offer the client fluids after every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate. Therefore, the client should tell the nurse when she would like a drink.
A nurse in a provider's office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications? Zoster vaccine Acyclovir Amoxicillin Infliximab
Correct Answer: B. Acyclovir The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster. Incorrect Answers: A. The nurse should anticipate a prescription for the zoster vaccine for an older adult client to prevent herpes zoster. C. The nurse should anticipate a prescription for amoxicillin for a client who has a bacterial infection. D. The nurse should anticipate a prescription for infliximab for a client who has Crohn's disease.
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? Instruct the client to blink several times after instilling the medication Ask the client to look straight ahead during instillation of the medication Apply pressure to the puncta after instilling the medication Place each drop of the medication directly onto the client's cornea
Correct Answer: C. Apply pressure to the puncta after instilling the medication The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication. Incorrect Answers: A. The nurse should instruct the client to close the eyes gently and to avoid blinking after instillation to prevent any loss of the medication out of the eye and promote absorption. B. The nurse should instruct the client to look upward toward the ceiling during instillation of the medication to allow proper placement of the medication and to suppress the client's blink reflex. D. The nurse should instill the medication into the client's conjunctival sac and should take measures to protect the client's cornea during administration.
A nurse is teaching a group of newly licensed nurse managers about the principle of justice. Which of the following statements by a nurse manager indicates an understanding of this teaching? "I will refer an unhappy employee to the individual with whom a conflict arose." "I will allow staff members to schedule their birthday holidays on alternate days, as long as staffing levels are maintained." "I will encourage staff participation in choosing new telemetry monitors for the unit." "I will compose staff schedules so that each person works two holidays a year."
Correct Answer: D. "I will compose staff schedules so that each person works two holidays a year." Justice means treating everyone fairly. By scheduling each person to work two holidays per year, the nurse manager is requiring staff members to work an equal share of holidays. Incorrect Answers: A. This is an example of the appropriate use of conflict management. By referring unhappy staff members to the individuals with whom they have conflicts, the nurse manager is encouraging individual problem-solving behaviors. B. This demonstrates the principle of autonomy. By allowing staff members to participate in scheduling while maintaining appropriate levels of staffing, the nurse manager is encouraging independent, professional behavior. C. This is an example of change theory. By allowing staff members to participate in decision-making for the unit, the nurse manager is encouraging staff input in the change process.
A nurse in a provider's office is documenting the results of a general survey of a client who is new to the practice. The client reports an inability to find pleasure in any activities she previously enjoyed. Which of the following terms should the nurse use to describe the client's mood? Anergia Flat affect Apathy Anhedonia
Correct Answer: D. Anhedonia Anhedonia is an inability to experience pleasure. This finding is especially concerning when the client no longer enjoys the activities that once produced pleasure. Incorrect Answers: A. Anergia is total passivity or a lack of energy. B. A client who has a flat affect shows no facial expression at all. C. A client who is apathetic is indifferent and does not show interest in anything.
A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). Which of the following pieces of information should the nurse include in the teaching? Add fortified rice cereal to the infant's formula Alternate feedings between several family members Offer the infant juice between feedings Provide feedings on demand rather than on a schedule
Correct Answer: A. Add fortified rice cereal to the infant's formula The nurse should inform the guardians that adding fortified rice cereal or vegetable oil to the infant's formula helps promote weight gain. Incorrect Answers: B. The nurse should inform the guardians that caregiver consistency is recommended when providing feedings for the infant who has FTT. This consistency promotes the development of trust and attachment. C. The nurse should recommend restricting the infant's intake of juice until adequate weight is gained through prescribed sources of formula. D. The nurse should inform the guardians of the need to maintain a schedule for feeding times to promote weight gain and behavior modification.
