ATI #2

A nurse is caring for a client who had a right sided stroke and is exhibiting homonymous hemianopsia when eating. which of the following actions should the nurse take? a. provide a non skid mat to alleviate plate movemnt b. encourage client to use his right hand when feeding himself c. remind client to look for food on left side of tray d. encourage use of wide grip utensils

C. Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse in a dermatologist's office is planning educational session about skin cancer. Which of the following should hte nurse include as a risk factor? select all that apply a. dark skin b. under 40 years old c. overexposure to UV light d. previous skin injury e. genetic predispostion

Dark skin is incorrect. Light-skinned individuals are at greater risk for developing skin cancer. Under 40 years of age is incorrect. Individuals over 60 years of age are at greater risk for developing skin cancer. Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for developing skin cancer. Previous skin injury is correct. Previous skin injury that resulted in a scar is a risk factor for developing skin cancer. Genetic predisposition is correct. Genetic predisposition is a risk factor for developing skin cancer.

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? select all that apply a. genetic predisposition b. hypercholesterolemia c. HTN d. obesity e. smoking

Genetic predisposition is incorrect. Although it is a risk factor for heart disease, clients cannot change their genetic predisposition. They should focus on the risk factors they can change. Hypercholesterolemia is correct. Cholesterol levels outside the healthful range increase clients' risk for heart disease, and they can change these levels. Hypertension is correct. Although it may not always be possible to eliminate hypertension, clients can change their blood pressure levels and thus reduce their risk for atherosclerosis. Obesity is correct. Clients who are overweight or obese can reduce their risk for heart disease by losing weight. Smoking is correct. Clients who smoke can reduce their risk for heart disease by quitting smoking.

A nurse is caring for a client who has emphysema. which of the following findings should the nurse expect to assess in the this client? select all that apply a. dyspnea b. bradycardia c. barrel chest d. clubbing on the fingers e. deep respirations

a. Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues c. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. d. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching? a. eating a high fiber diet will reduce my risk for developing skin cancer b. I should check my skin monthly for any changes c. I should avoid the use of tanning booths d. I should use sunscreen even on cloudy days

a. eating a high fiber diet will reduce my risk for developing skin cancer A high-fiber diet is recommended to reduce the risk for colon cancer.

A nurse at a rehabilitation center is planning care for a client who had a left CVA three weeks ago. Which of the following goals should the nurse include in the client's rehab program? a. establish ability to communicate effectively b. compensate for loss of depth perception c. learn to control impulse behavior d. improve left sided motor function

a. establish ability to communicate effectively A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is providing discharge teaching to a client who has a new dx of heart failure. Which of the following should hte nurse include in the teaching? a. exercise at least 3x a week b. take diuretics early in the morning and before bedtime c. notify provider of a weight gain of 1lb in a week d. take naproxen for generalized discomfort

a. exercise at least 3x a week The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? a. frothy sputum b. dependent edema c. nocturnal polyuria d. jugular distention

a. frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness all the other three options are indicative of R sided HF

A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nruse plan to include? a. keep a body map of skin lesions b. examine your body every 2 months for lesions c. avoid sun after 3pm d. limit tanning bed use

a. keep a body map of skin lesions A body map of scars, spots and lesions will help clients monitor for new growth and changes to lesions to help detect skin cancer.

A nurse is planning to administer digoxin to a client who has HF. Which of the following lab tests is the priority for the nurse to review before administration? a. potassium b. hemoglobin c. creatnine d. BUN

a. potassium Digoxin is a cardiac glycoside medication used to improve myocardial contractility, increasing stroke volume and cardiac output in a client who has heart failure. During therapy, the nurse should closely monitor the client's potassium level as hypokalemia increases the risk of digitalis toxicity and cardiac arrhythmias.

A nurse is teaching a client about risk factors for skin cancer. Which of the following statements by the client indicates an understanding of the teaching? a. "Because im dark-complected, I won't have to worry about skin cancer" b. "I should apply sunscreen prior to going outside, even in winter months" c. I used to lie in the sun all the time, but I now know the tanning bed is a better option: d. My father was treated for melanoma, but skin cancer is not related to genetics"

b. "I should apply sunscreen prior to going outside, even in winter months" Almost all cases of skin cancer diagnosed each year are considered to be sun related. Clients should use sunscreen daily to minimize the negative effects of ultraviolet rays and should reapply it every 2 hr.

A nurse is teaching a client who has COPD about ways to facilitate eating. Which of the following statements indicates a need for further teaching? a. I will rest for at least 30 min before eating b. I will take my bronchodilators after meals c. I will eat five or six small meals a day d. I will choose foods that are not gas-forming

b. I will take my bronchodilators after meals Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.

A nurse is providing care for four clients on a med surg unnit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? select all that apply a. a client who is ambulatory following a cardiac cath 4h ago b. a client who has type I DM and is hyperglycemic c. a client who has protein calorie malnutrition d. a client who has R sided HF and 4+ edema on lower extremities e. a client who has postoperative delirium

b. a client who has type I DM and is hyperglycemic c. a client who has protein calorie malnutrition d. a client who has R sided HF and 4+ edema on lower extremities e. a client who has postop delirium

A home health nurse visits a client who has COPD and receives O2 at 2L/min via nasal cannula. Client reports difficulty breathing. Which action is nurse's priority? a. increase O2 flow to 3L/min b. assess client resp status c. call ER services for client d. have client cough and expectorate secretions

b. assess client resp status The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

A nurse is providing discharge teaching to a client following an excisional biopsy of a skin lesion. Which of the following information should hte nurse include in the teaching? a. keep the dressing in place for at least 24 hours b. clean the incision site daily after the dressing is removed c. use hydrogen peroxide to clean the incisional site d. the sutures will be removed in 2 weeks

b. clean the incision site daily after the dressing is removed The nurse should instruct the client to clean the incisional site daily after the dressing is removed.

a nurse is assessing a client who has rigth ventricular failure. Which of the following findings should the nurse expect? a. dry, hacking cough b. hepatomegaly c. dizziness d. crackles in lungs

b. hepatomegaly Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

A nurse is caring for a client who has had a stroke involving the R hemisphere. Which of the following alterations in fx should the nurse expect? a. difficulty reading b. inability to recognize family members c. right hemiparesis d. aphasia

b. inability to recognize family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

a nurse is teaching a client who has COPD and is about to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include? a. check your HR before each dose b. inspect mouth for lesions daily c. use this med to relieve an acute attack d. skip morning dose if you do not have symptoms

b. inspect mouth for lesions daily The nurse should instruct the client to inspect her mouth daily. Fluticasone is a corticosteroid, which reduces the client's immunity and increases the risk for infection, such as Candida albicans.

A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse requires interventions by the nurse's supervisor? a. nurse wears an N95 mask b. the nurse admits another client who has shingles to the client's double room c. the nurse wears gloves when providing direct care to client d. the nurse wears a gown when bathiing the client

b. the nurse admits another client who has shingles to the client's double room When a private room is not available, clients who are infected with the same organism may be placed together in a double room. However, cohorting is reserved for clients who both require droplet precautions. This client should be in a private room.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which fo the following instructions should the nurse include? a. encourage brief exercise before meals to promote appetite b. place food in the affected side of the mouth c. encourage client to take small bties d. place client who head reclined back to facilitate swallowing

c. encourage client to take small bites The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.

A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should hte nurse incllude as effetive for preventing this disorder? a. maintenance of ideal weight b. annual flu vaccine c. smoking cessation d. regular moderate exercise

c. smoking cessation Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I cannot seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? a. maintaining a semi-fowler's position as often as possible b. administering oxygen via nasal cannula c. helping client select a low salt diet d. encouraging the client to drink 2-3 L of water daily

d. encouraging the client to drink 2-3 L of water daily COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse is assessing a client who has left sided heart failure. Which of the following findings should the nurse expect? a. jugular vein distention b. abd distention c. dependent edema d. hacking cough

d. hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse is developing a plan of care for a client who has COPD. The nurse should indicate which of the following interventions in the plan? a. restrict client fluid intake to less than 2L/day b. provide client with a low protein diet c. have the client use early morning hours for exercise and activity d. instruct client to use pursed-lip breathing

d. instruct client to use pursed-lip breathing Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize which of these findings as manifestations of what condition? a. asthma b. aortic valve regurgitation c. heart failure d. aortic stenosis

heart failure Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.