ATI Challenge 7

A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the following information should the nurse include in the teaching?

"Encourage your child to avoid sharing hats with other children."

A nurse is caring for a client who has Alzheimer's disease and is obtaining data from their partner who is their full-time caregiver. Which of the following responses by the partner should the nurse identify as a potential concern?

"I get agitated when they don't eat their food at mealtime."

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

"I'll be glad when I can stop taking this medicine."

A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

"Incorporate nonverbal cues in the conversation."

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include?

"Report swelling of eyelids after dosage."

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 preparing to administer valproic acid 400 mg PO bid for migraine headaches. Available is valproic acid 250 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

A client who is unresponsive to verbal commands and changes position occasionally

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

A private room

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

A reddened area over the sacrum

A community health nurse is preparing an educational activity on Alzheimer's disease. Which of the following risk factors should the nurse include as the greatest risk for this disease?

Age

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the client's skin.

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Ask the client to read a Snellen chart.

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII?

Ask the client to stick out their tongue and observe if its midline.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves.

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?

Assist the client to the correct room.

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Basal cell carcinoma

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

Cheddar cheese

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse is discussing a client's needs at an interdisciplinary team conference. The client had a stroke and requires inpatient rehabilitation incorporated into their plan of care. Which of the nursing competencies is the nurse demonstrating?

Collaborator

A nurse is reviewing the medical record of a client who has moderate Alzheimer's disease. Drag words from the choices below to fill in each blank in the following sentence.

Continue bowel training program and record strict nutritional content are correct.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist, sterile gauze dressing.

A nurse is caring for a client who has a wound that requires negative pressure wound therapy. Which of the following actions should the nurse take?

Cut a round hole in the center of the outer dressing

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client?

Dim lighting installed throughout the house is correct The hot water heater is set at 54ºC (130º F) is correct. Medications are stored in a clear bag is correct Area rugs are placed in the living room is correct

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container.

A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take?

Encourage oral fluids.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Encourage the client to take small bites.

A nurse is caring for a client who is desiring their wound care to be provided at 1400. The nurse returns at 1400 to perform wound care for the client. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound?

Film dressing

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include?

Genetics

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I?

Have the client identify specific smells.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

A nurse is planning care for a client who has an infected wound with significant exudate. The nurse should plan to use which of the following dressings to cover the wound?

Hydrofiber dressing

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan?

Identify effective stress reduction techniques.

A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (Select all that apply.)

Inability to perform common tasks is correct. Difficulty with talking or reading is correct. Inability to recognize family members is incorrect.

A nurse is caring for a client who has a pressure injury. Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect information, click on the information again.

Increased redness at wound borders and purulent drainage noted. Temperature 38.9° C (102° F) WBC 12,000/mm3 (5,000 to 10,000 mm3)

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Intact skin with localized erythema

A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nurse plan to include?

Keep a body map of skin lesions.

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take?

Keep familiar personal items at the bedside.

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levodopa/carbidopa

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

Montgomery straps

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

Observe for facial symmetry while the client smiles.

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI?

Observe for the ability of the client to turn their head side to side

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access.

A school nurse is assessing a school-age child and notices white flakes that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders?

Pediculosis capitis

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs

A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

Prealbumin level is correct. History of diabetes mellitus is correct. Wound infection is correct Decreased pedal perfusion is correct Fasting blood glucose is correct.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision.

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse is assessing a client who has a new skin lesion that has a wavy border. The nurse should document the lesion using which of the following descriptions?

Serpiginous

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

Serum albumin 3.2 g/dL

A nurse in the outpatient clinic is assessing a client who has psoriasis. The nurse should expect which of the following findings?

Silvery, white scales

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through tasks one step at a time.

A nurse is caring for a client who has had a stroke. Select the 3 findings that require immediate follow-up.

Temperature at 1800 is correct Drooling is correct Hoarse voice is correct

A nurse is caring for a client on the medical-surgical floor. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The client is most likely experiencing a hemorrhagic stroke. Prepare the client for a STAT CT and place the client on seizure precautions. Monitor the clients blood pressure and PT/INR

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The nurse should first place a waterproof pad on the bed under the client's leg to prevent soiling the bed linen. The nurse should then apply clean gloves to remove and discard the old dressing. Next, the nurse should clean the puncture site using a circular motion, moving from the cleanest area in the center of the wound outward. After cleaning the wound, the nurse should prepare the equipment necessary for irrigation by opening a sterile dressing set and supplies. Finally, the nurse should irrigate the wound until the solution becomes clear to ensure that exudate is no longer present.

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

The nurse should remove the most contaminated item of PPE first and the least contaminated item last. The gloves are the most contaminated, so the nurse should remove them first, and then the eyewear, the gown, and finally, the mask. Finally, the nurse should perform hand hygiene and then leave the room.

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lb in the past 2 months.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

Use pillows to keep heels off the bed surface is correct. Minimize skin exposure to moisture is correct

A nurse is admitting a young adult client who has suspected bacterial meningitis. The nurse should closely monitor the client for increased intracranial pressure (ICP) as indicated by which of the following findings?

Widened pulse pressure