ATI Test 4

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? "Turn the screws on the device once each day." "The purpose of this device is to immobilize the cervical spine." "Apply talcum powder under the vest to limit friction." "The purpose of this device is to allow for neck movement during the healing process."

"The purpose of this device is to immobilize the cervical spine."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? "These tests help determine the degree of damage to the heart tissues." "Cardiac enzymes will identify the location of the MI." "These tests will enable the provider to determine the heart structure and mobility of the heart valves." "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

"These tests help determine the degree of damage to the heart tissues."

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the rule of nines, the nurse should estimate that the client has burned what percentage of body surface area?

31.5%

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? Airway obstruction Infection Fluid imbalance Paralytic ileus

Airway obstruction

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) Confusion Bradycardia Hypotension Nonreactive dilated pupils Slurred speech

Bradycardia Nonreactive dilated pupils

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? Decreased level of consciousness Tachypnea Bilateral weakness of extremities Hypotension

Decreased level of consciousness

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? Teach controlled coughing and deep breathing. Provide a brightly lit environment. Elevate the head of the bed. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.

Elevate the head of the bed.

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? Blistering Erythema Eschar Absence of pain

Erythema

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take? Fill the client's bathtub with water at 48° C (118.4° F). Provide the client with a fixed showerhead. Give the client a long-handled sponge. Offer the client bar soap.

Give the client a long-handled sponge.

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.) Genetic predisposition Hypercholesterolemia Hypertension Obesity Smoking

Hypercholesterolemia Hypertension Obesity Smoking

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin

Hyperkalemia

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) Hypotension Polyuria Hyperthermia Absence of bowel sounds Weakened gag reflex

Hypotension Absence of bowel sounds Weakened gag reflex

A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? Brisk pupillary reaction to light. Increased sleeping Tachycardia Depressed fontanels

Increased sleeping

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take? Obtain an EKG. Administer enteric-coated acetaminophen. Administer ibuprofen. Maintain oxygen saturations greater than or equal to 92%.

Obtain an EKG.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? Paresthesia Hemiplegia Quadriplegia Paraplegia

Paraplegia

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? Pushes the painful stimulus away Extends her body toward the painful stimulus Shows no reaction to the painful stimulus Flexes the upper and extends the lower extremities in response to the painful stimulus

Pushes the painful stimulus away

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication? Reduce edema of the brain. Provide fluid hydration. Increase cell size in the brain. Expand extracellular fluid volume.

Reduce edema of the brain.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? Tachycardia Amnesia Hypotension Restlessness

Restlessness

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? Photophobia Nuchal rigidity Positive Kernig's sign Restlessness

Restlessness

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? Troponin I Lipase B-type natriuretic peptide (BNP) Aspartate aminotransferase (AST)

Troponin I

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.) Troponin I Troponin T Plasma low-density lipoproteins (LDL) CPK Myoglobin

Troponin I Troponin T CPK Myoglobin

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? Instruct the client to cough and deep breathe. Place the client in a supine position. Place a warming blanket on the client. Use log rolling to reposition the client.

Use log rolling to reposition the client.

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? analgesic anti-inflammatory antiplatelet aggregate antipyretic

antiplatelet aggregate

A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? "Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." "Exercise is good for you and good for your heart." "Your doctor is the expert here, and I'm sure he would only recommend what is best for you."

"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make? "You might feel a slight tingling while the test is being done." "The test will be complete in 30 to 60 minutes." "I will need to apply electrodes to your chest and extremities." "The radioactivity from the dye lasts only a few hours."

"I will need to apply electrodes to your chest and extremities."

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. which of the following nursing statements is appropriate? "Large incisions will be made in the eschar to improve circulation." "This procedure involves placing the client into a shower and removing the dead tissue." "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." "Dead tissue will be non-surgically removed."

"Large incisions will be made in the eschar to improve circulation."

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? "Place the tablet under your tongue, and then take a small sip of water." "The medication can take up to 15 minutes to take effect." "Avoid taking the medication prior to exercising." "Stop taking the medication and notify your provider if you develop a headache."

"Place the tablet under your tongue, and then take a small sip of water."

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? Urinary output 25 mL/hr Difficulty swallowing Heart rate 122/min Pain of 6 on a scale of 0 to 10

Difficulty swallowing

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Inform the client that privileges are related to participation in therapy. Limit visiting hours until the client begins to participate in therapy. Allow the client to control the timing and frequency of therapy. Establish a plan of care with the client with mutually set attainable goals

Establish a plan of care with the client with mutually set attainable goals

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) Headache Neck pain and stiffness Slurred speech Pupillary changes Disorientation

Headache Slurred speech Pupillary changes Disorientation

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? Attach the leads for a 12-lead ECG. Obtain a blood sample. Initiate oxygen therapy. Insert the IV catheter.

Initiate oxygen therapy.

A nurse is planning care for a client who is 1 day postoperative following spinal fusion. Which of the following actions should the nurse include? Log roll the client every 2 hr. Assist the client to sit upright in a chair for 4 hr at a time. Expect clear drainage on the spinal dressing. Perform neurological checks every 8 hr.

Log roll the client every 2 hr.

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? Albumin 25% Dextran 70 Hydroxyethyl glucose Mannitol 25%

Mannitol 25%

A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take? Monitor sensory perception of the lower extremities. Assist the client into a knee-chest position to manage postoperative discomfort. Maintain strict bed rest for the first 48 hours postoperative. Position the client in a high-Fowler's position if clear drainage is noted on the dressing.

Monitor sensory perception of the lower extremities.

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care? Monitor the client for an elevated temperature. Provide range of motion to the client's neck. Remove the vest daily to inspect the client's skin integrity. Check that the halo jacket is snug against the client's skin.

Monitor the client for an elevated temperature.

A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system? Auscultate cuff blood pressure. Palpate pulse pressure. Obtain a central venous pressure. Monitor the pulmonary artery pressure.

Monitor the pulmonary artery pressure.

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety? Nitroglycerin Aspirin Oxygen Morphine

Morphine

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? The client states having a severe headache. The client's bladder becomes distended. The client's blood pressure becomes elevated. The client states having nasal congestion.

The client's bladder becomes distended.

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. Troponin is a lipid whose levels reflect the risk for coronary artery disease. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a protein that helps transport oxygen throughout the body.

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.