HEENT Quiz ATI

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team." Documentation provides information to facilitate communication among members of the interprofessional health care team in making client-centered decisions, planning appropriate therapies and evaluating a client's progress.

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which client should the nurse assign to the room closest the nurse's station?

A client who sustained a head injury and is having periods of confusion

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment

An assistive personnel reports a client's vital signs as tympanic temperature 37.1, pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as well as which of the following disorders?

Bruxism

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher tray.

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

Collect and organize client data

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse is having difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids.

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Determine the client's level of fluency in his primary language

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

Grape juice

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team?

Occupational therapist

A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sounds in his temporomandibular joint. Based on these findings, to which of the following providers should the nurse request a referral for the client?

Oral surgeon

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver.

A nurse is caring for a client. Client is admitted with a productive cough for thick yellow sputum.

T 38.6 Apical HR 108/min

A nurse is caring for a client. Client reports diarrhea and dizziness for 24 hrs and dizziness.

T38 BP 106/60 mm Hg, supine HR 99/min

A nurse is caring for a client. For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged?

Temperature has worsened. Respiratory rate has improved. Pulse oximetry has improved. Blood pressure is unchanged. Mucous membrane color has improved.

A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver?

The client is not making any sounds

A nurse is providing care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting care

A nurse is caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact.

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Wait 30 min and return to measure the oral temperature

A nurse is orienting a new assistive personnel to the unit. For which of the following actions should the nurse intervene?

Washes and rinses her hands for 10 seconds

A nurse is caring for a client whose partner asks to speak with the nurse. The partner relates her concerns about her spouses abusing alcohol and having difficulty maintaining employment. Which of the following response should the nurse make?

What have you done in the past to cope with this issue?