ATI Comprehensive
A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer. When discussing the client's prognosis with the parents, the nurse should recognize which of the following responses by the parents as an example of rationalization?
"Our child wouldn't have this terminal diagnosis if the doctor had diagnosed the cancer sooner."By attributing the cause of the adolescent's prognosis to the provider's failure to diagnose the illness sooner, the parent is using the defense mechanism of displacement. "Let's go on that family vacation we've got planned. We will deal with this when we return."By exhibiting a conscious denial of the adolescent's prognosis until the family returns from vacation, the parent is using the defense mechanism of suppression. "Maybe this is better for our child because we don't want any suffering through chemotherapy treatments."MY ANSWERBy justifying the adolescent's prognosis by searching for a more personally acceptable explanation for the impending loss, the parent is using the defense mechanism of rationalization. "This isn't possible. Just last week the doctor said that the cancer was responding well to treatment."By focusing on disbelieving the news about the adolescent's prognosis, the parent is using the defense mechanism of denial.
A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first?
Determine the client's perception of the personal impact of the crisis. MY ANSWER The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first determine the client's feelings and understanding of the natural disaster and its personal impact.
A nurse is caring for a client who has a deep vein thrombosis. Which of the following actions should the nurse take?
Instruct the client to elevate the affected extremity when sitting. The nurse should instruct the client to elevate the affected extremity when in the bed or chair. Warm, moist compresses
Complete the diagram by dragging from the choices below to specify what condition the child is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the child's progress.
The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottitis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds.
A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation. Client is a primigravida who presents with report of decreased fetal movement and new onset of a small amount of dark red vaginal bleeding. External fetal monitor applied; FHR 116/min. Scant amount of dark red blood noted on perineal pad. Client reports sudden onset of pain above umbilicus and occasional uterine tightening over past hour. +1 nonpitting edema noted to feet and ankles. Denies visual changes, heartburn.
The nurse should avoid cervical examination and insert a large-bore IV catheter because the client is most likely experiencing abruptio placentae indicated by the sudden onset of abdominal pain, contractions, and dark red vaginal bleeding. Cervical examination can cause further damage to the placenta and increase bleeding. The nurse should immediately establish IV access with a large-bore catheter to administer IV fluids and blood products if bleeding increases or if manifestations of fetal distress occur. The nurse should monitor the client's blood pressure and platelet count because of the risk of significant blood loss due to the abruption. Hemorrhage might not be visible as vaginal bleeding if it is concealed between the placenta and uterine wall. Therefore, manifestations of hypovolemic shock (decreasing blood pressure, increasing heart rate) can provide indications that internal placental bleeding is worsening. Abruptio placentae can also lead to alterations in coagulation, such as disseminated intravascular coagulation, further increasing the client's risk for hemorrhage. Therefore, the nurse should monitor the client's platelet count to identify if the client is at an increased risk for bleeding.
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.
Upon recognizing and analyzing the client cues of decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges, the nurse's priority hypotheses should be that this client is most likely experiencing neuroleptic malignant syndrome, which is related to the client's haloperidol therapy. It is important to generate solutions and take actions that will decrease the client's temperature, blood pressure, heart rate, and respiratory status, which will improve the client's neurological status. The nurse should hold the client's antipsychotic medications and apply a cooling blanket to reduce the client's temperature. Neuroleptic malignant syndrome is a life-threatening condition. Therefore, the nurse should monitor the client's laboratory and arterial blood gas values as multiorgan failure can occur. To evaluate interventions and track the client's condition, the nurse should monitor the client's temperature, hydration status, and provide for early detection of complications.
For each condition, click to specify if the characteristic is consistent with an acute infection of hepatitis A, hepatitis B, or hepatitis C. Each characteristic may support more than one disease process.
When analyzing cues, the nurse should recognize that manifestations of hepatitis A, hepatitis B, and hepatitis C include jaundice, yellow sclerae, right upper quadrant pain upon palpation, dark yellow urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an underdeveloped country and the client's occupational risk as a perioperative nurse for contracting hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the current standard of practice for treating hepatitis B and hepatitis C infections is with antiviral medication.
A nurse is assessing a newborn who is 3 days old.
When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respiratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.
For each assessment finding, click to specify if the assessment finding is consistent with bacterial meningitis, encephalitis, or Reye syndrome. Each finding may support more than 1 disease process.
When recognizing cues, the nurse should recognize that manifestations of bacterial meningitis can include fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness. The adolescent is experiencing these symptoms. Encephalitis is characterized by fever, nuchal rigidity, and altered mental status. Reye syndrome is characterized primarily by altered mental status and impaired hepatic function.
A nurse is caring for a client following a laparoscopic cholecystectomy.
When taking actions for a client who is postoperative following a laparoscopic cholecystectomy, the nurse should anticipate prescriptions for the client to apply heat for abdominal pain as needed, to encourage deep breathing, and to change the dressing when soiled. The client can use heat for abdominal pain related to carbon dioxide retention. During the procedure, carbon dioxide is inflated into the abdominal cavity for visualization for the provider. The client's dressing should be changed when soiled as needed. The dressing should be clean, dry, and intact to prevent infection. The nurse should identify that medication for nausea should be provided as needed and is contraindicated for scheduled administration.
Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management.
When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypotonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells and assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection.
A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to first remove the inner cannula. Next, the nurse should instruct the parent to remove the soiled dressing and then clean the stoma with 0.9% sodium chloride irrigation. Finally, the nurse should instruct the parent to change the tracheostomy collar.
