NUR 325 ATI quiz questions
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? a- a needless syringe and a doll b- a video game c- a story book about a child who has diabetes d- a period of play in the playroom
a- this a therapeutic activity for a child because they will allow the child to act out feelings of anger and helplessness -a video game is a distraction, the activity book does not provide an outlet for working out the feelings that a child is unable to verbalize, playing in the playroom is not therapeutic in this activity
a nurse is caring for a client who is grieving following the death of her husband 7 months ago. The client reports that she lost 30 lbs and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? a- the client is 48 years old b-the client's husband died seven months ago c- the client has lost 30 pounds d- the client is having difficulty sleeping
b- one of the defining characteristics of maladaptive grieving is grief that lasts 6 months or longer after the loss. -weight loss and insomnia are common findings in the grief process
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? a-Blood pressure b-Cyanosis c-Nausea d-Petechiae
c- Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated. Objective data include information the nurse can observe or measure.
A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on their forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? a- Inspecting the site for reduced swelling b- Monitoring the client's pulse rate c-Asking the client to rate the pain d-Having the client perform range-of-motion of the affected arm
c-Pain is a subjective experience. The nurse should encourage the client to quantify the pain on a pain scale before, during, and after cold application to determine its effectiveness. -Ice and cold applications help reduce redness, swelling, and pain because they cause vasoconstriction and numbness. However, pain can persist even with reduced swelling. -Localized pain from a laceration is unlikely to affect the client's temperature unless the laceration is infected, making this an unreliable indicator of the effect of cold application. -Depending on the location, length, and depth of the laceration, the client might or might not be able to move the arm without pain, making this an unreliable indicator of the effect of cold application.
a nurse is caring for a client who was involved in a heavy combat and observed war casualties. The nurse should suspect that the client is suffering PTSD if the client makes which of the following statements? a-"I check any room I enter because the enemy is still after me and could be hiding anywhere" b-" My child was born with a birth defect due to an exposure I had overseas" c-"I killed four enemy soldiers with my bare hands and saved my entire battalion." d- "In my dreams, all I can see are the wounded reaching out and trying to grab me."
d- Many clients with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when exposed to events or objects reminiscent of the trauma.
A nurse is caring for a client who has dementia. When performing a Mental status examination the nurse should include which of the following data?(Select all that apply) Ability to perform calculations Level of consciousness Recall ability Long-term memory Level of orientation
Evaluating the client's ability to perform calculations is an included component of an MSE. Determining the client's level of consciousness is not a component of an MSE. Identifying the client's ability to recall a list of objects or words is an included component of an MSE. Evaluating long-term memory is not a component of an MSE. Determining the client's level of orientation is an included component of an MSE.
A nurse is caring for a client who has a new diagnoses of dementia. When performing a Mental status examination the nurse should include which of the following data? (Select all that apply) Grooming Long-term memory Support systems Affect Presence of pain
Grooming, long term memory, and affect, are included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others. Not pain and support systems
What are the 3 components of a mental status assessment?
1.- general appearance and behavior-grooming, dressed appropriately 2.cognition-use MMSE, MoCA, Confusion Assessment method 3.-Mood and Affect-agitation, euphoria, depression
A nurse is admitting a client who has experienced a weight-loss of 11 kg/25 Lbs in 3 months. The client weighs 40 kg(88lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority of care for this client? a- identify the client's nutritional status b- request a mental health consult c-plan a therapeutic diet for the client d- provide a structured environment for the client
A- according to the nursing process the nurse should perform an assessment first to gather data regarding nutritional status and other findings in order to plan, implement, and evaluate care. - mental health consult might be necessary but another aspect of care is priority -it is important to provide structured environments for the client regarding meal times, for weighing, and monitoring eating- but other aspects of care is the priority
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client? a-Client concerns b-Family information c-Medical history d-Progress note
A-Information the nurse obtains directly from the client is generally the most accurate and provides the best information available. The client is a primary source of information. The other options are all secondary sources of information
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? a- Hypotension b- viral infection c- increased energy d- increased cognitive awareness
B-viral infection because chronic stress can cause a decreased immune response which leads to viral or bacterial infections -the nurse should expect to find the client hypertensive due to increased cardiac tone from the response to chronic stress - you would expect to find decreased energy and decreased memory and ability to learn
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? a- a client wants to know the current time while theres a clock on the wall b- a client attempts to climb out of bed and repeatedly states she must get home c- a client requests extra blankets when the thermostat in the room indicates 78 degrees Fahrenheit d- a client refuses to get out of bed and has no motivation to attend to daily hygiene
B- Delirium is characterized by a change in cognition that occurs over a short period of time. It results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur with any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely confused and agitated may be showing manifestations of delirium.
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? A-Critically analyze client data to determine priorities. b-Collect and organize client data. c-Set client-centered, measurable and realistic goals. d-Determine effectiveness of interventions.
B- The steps in the nursing process include assessment, analysis/diagnosis, planning, implementation and evaluation. The nurse should first collect client data, and then critically analyze the data to determine the clients' priorities. This is followed by the nurse planning client-centered, measurable and realistic goals. The nurse implements care, which involves putting the plan into action, followed by evaluation to determine the effectiveness of the interventions.
A nurse is performing a pain assessment for a client who is alert. Which is the most reliable measure of pain? a-Vital signs b-Self-report of pain c-Severity of the condition d-Nonverbal behavior
B- self report of pain-According to evidence-based practice, the most reliable indicator of pain is the client's self-report of pain. A pain intensity scale is a reliable tool to identify the client's pain level. -The nurse should assess the client's vital signs when performing a pain assessment to monitor for a change. However, evidenced-based practice indicates that another assessment is the most reliable indicator of pain. Acute pain can cause a stimulation of the sympathetic nervous system causing an increase in blood pressure, heart rate, and respiratory rate. This response is decreased or absent in client's who have prolonged stimulation or chronic pain. Therefore, a client's vital signs are not a reliable indicator of pain. -The nurse should consider the severity of the condition causing pain when performing a pain assessment to determine treatment. However, evidenced-based practice indicates that another measure is the most reliable indicator of pain. -the nurse should assess the client's nonverbal behavior to assess for indications of pain. However, evidenced-based practice indicates that another assessment is the most reliable indicator of pain. Nonverbal behavior, such as grimacing, restlessness, and holding an arm over the painful area, are nonverbal responses to pain. However, non-verbal behaviors are controllable and this response is decreased or absent in client's who have chronic pain. Therefore, a client's nonverbal behavior is not a reliable indicator of pain.
A nurse at a college campus mental health counseling center is caring for a student who just failed an exam. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? a- conversion b- projection c- undoing d- regression
B- the client is refusing to acknowledge unacceptable personal characteristics and transfers feelings, thought and traits onto another person. -conversion as a defense mechanism in which the client unconsciously expresses emotional conflict via physical symptoms - such as paralysis or loss of sensory function -undoing is a defense mechanism in which the client takes an action to make up for a wrong action or statement -regression is a defense mechanism in which the client adopts a more primitive, immature behavior in response to an unwanted situation
A nurse is caring for a client who is postoperative. the nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? a-Vital sign measurement b-The client's self-report of pain severity c-Visual observation for nonverbal signs of pain d-The nature and invasiveness of the surgical procedure
B-Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly. -Pain can affect vital signs, for example, causing tachycardia, but this is not a reliable indicator of pain for all clients at all times. -Nonverbal signs, such as grimacing, can indicate pain, but this is not a reliable indicator of pain for all clients at all times. -The nature and invasiveness of a surgical procedure is useful for predicting that the client will experience pain, but it does not indicate how severe a client's pain is at any particular time.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? a-Set the pad's temperature to 47.2° C (117° F). b-Stop the treatment if the client's skin becomes red. c-Leave the pad in place for at least 40 min. d-Use safety pins to keep the pad in place.
B-Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider. -The temperature setting for most aquathermia pads is 40° C (104° F). -The heat application should last no longer than 30 min. -Safety pins can puncture the pad and cause leakage. The nurse should use gauze or tape to keep the pad in place.
A nurse is observing a client's non verbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal behavior? a-Nonverbal communication conveys less truth than what the client states verbally. b-The client's sociocultural background influences nonverbal communication. c-Nonverbal communication is a poor reflection of what the client feels. d-The client enacts nonverbal communication consciously.
B-Sociocultural background has a major influence on what a client's nonverbal behavior means. -Nonverbal behavior might or might not reflect what the client states verbally. The nurse should not consider it less truthful than verbal statements. -Nonverbal behavior is often an accurate reflection of what the client really feels. -Nonverbal behavior is often subconscious. The client doesn't necessarily plan it.
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A-Reposition the client. B- Administer the medication. C-Determine the location of the pain. D-Review the effects of the pain medication
C-The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication. -The nurse should reposition the client to help reduce the pain, but there is another action the nurse should take first. -The nurse should administer an analgesic to help reduce the client's pain, but there is another action the nurse should take first. -The nurse should reinforce teaching about the effects of analgesia so that the client will know what to expect and when to notify the nurse, but there is another action the nurse should take first.
nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (select all that apply) Offer the client a back rub. Remind the client to use incisional splinting. Identify the client's pain level. Assist the client to ambulate. Change the client's position.
Change the client's position is correct. Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. Identify the client's pain level is correct. The nurse should use a standard scale to determine and document the severity of the client's pain. Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning, imagery, and distraction. Incorrect= Assist the client to ambulate is incorrect. If the client reports pain, the nurse should implement interventions to manage the pain, such as administering analgesia and giving it time to take effect, before assisting the client to ambulate.
A nurse is monitoring a postoperative client who is unable to respond to questions, which of the following nonverbal behaviors should the nurse identify as indication that the client is in pain? Restlessness Grimacing Moaning Clenching Drowsiness
Restlessness, grimacing, and clenching are correct. Restlessness is correct. Clients who have uncontrolled pain often become restless and anxious in response to the discomfort. Grimacing is correct. Facial movements such as grimacing, tightly closing the eyes, and biting the lower lip are behavioral indicators of pain. Moaning is incorrect. Moaning, groaning, crying, and screaming are vocalizations, not nonverbal behaviors, that indicate pain. Clenching is correct. Clenching the teeth and biting the lower lip are common findings in clients who have pain. Drowsiness is incorrect. Agitation and aggressiveness, not drowsiness, are common indicators of pain.
A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? Select all that apply Teach balance and strengthening exercises. Provide information about home safety checks. Lock beds and wheelchairs when not providing care. Place the bedside table within the client's reach. Administer a sedative at bedtime.
Teach balance and strengthening exercises is correct. There is a strong correlation between exercise and fall risk reduction, especially when combined with balance training. Provide information about home safety checks is correct. The nurse should provide information about home safety checks, including removing loose rugs, the use of nightlights, and installing nonslip bathmats. Lock beds and wheelchairs when not providing care is correct. Locking beds and wheelchairs when not providing care allows the client to move in and out of bed easily. Place the bedside table within the client's reach is correct. Placing the bedside table within the client's reach keeps the client from overreaching and potentially losing her balance. Administer a sedative at bedtime is incorrect. Administering a sedative at bedtime can increase the client's risk for falls due to the effects of the medication.
The nurse at the 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? Planning Evaluation Assessment Implementation
The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.
A nurse is planning care for a patient who is postoperative . which of the following statements about pain management should the nurse consider when implementing client care? Select all that apply Use of analgesics will eventually lead to addiction. Each client's expression of pain may be different and individualized. Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. Pain level and pain tolerance can be assessed using a scale from 0 to 10. The client will express the feeling of pain both verbally and nonverbally.
This one is the weird question that kept saying we got the answer wrong even though we tried everything
A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of the following clients should the nurse suggest offering the therapy to? a- PTSD b- Schizophrenia c-Pedophilia d- paranoid personality disorder
a- guided imagery is a recommended treatment to relive the anxiety associated with PTSD.
a nurse is assessing a parent who lost a 12- year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestation if prolonged grieving? a- leaves the child's room exactly as it was before the loss b-volunteers at a local children's hospital c-talks about the child in the past tense d- visits the child's grave every week after worship services
a- the client is unable to resume regular activities of daily living or experience emotions other than sadness or depression.
A nurse assumes a variety of roles while working with clients. Which of the following describes the nurse's role of protecting the client and supporting the client's decisions? a-Advocate b-Caregiver c-Manager d-Educator
a-A client advocate acts to protect clients' rights and helps clients to speak for themselves. -As a caregiver, the nurse assists clients with meeting their physical, psychological and developmental needs. -As a manager, the nurse works with clients and the interprofessional health care team to achieve positive care outcomes. -As an educator, the nurse works to enhance clients' knowledge about health promotion and disease prevention activities that protect clients' health, or allow them to function more independently.
A nurse is caring for a patient wit late stage Alzheimer's disease, and she is hospitalized for pneumonia. During the night she is found climbing into bed with another client who becomes upset wand frightened. Which action should the nurse take? a- Assist the client to the correct room. b-Place the client in restraints. c-Reorient the client to time and place. d-Move the client to a room at the end of the hall.
a-Assisting the client to the correct room protects both clients. It helps reorient the client who is unable to find her own room, and it protects the other client from an invasion of her personal space. -Restraining a client in situations other than for the client's physical safety is unethical and illegal. This action by the nurse is not appropriate. -This action does not address that the client went into another client's room. -The client should be placed in a room that can be monitored easily. Furthermore, moving the client to another room might increase the client's disorientation.
A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? Apply the bag for 30 min at a time Reapply the bag 10 min after removing it. Allow room for some air inside the bag. Place the bag directly on the skin.
a-The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects. -After removing the ice bag, the nurse should not reapply it any sooner than 1 hr later. -The nurse should squeeze the sides of the bag to remove excess air before putting the cap back on the bag. Air can block the conduction of cold to the injury. The nurse should place a towel, the bag's cover material, or a pillowcase between the ice bag and the client's skin.
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? Determine the time the client last received pain medication. Measure the client's vital signs, including temperature. Ask the client to rate her pain on a scale from 0 to 10. Reposition the client and offer her a back rub
c- Using evidence-based practice, the nurse should first determine the severity of the client's pain by using a standard pain scale. Then the nurse can plan the appropriate interventions. -If the nurse decides that the client requires pain medication, he will have to see when the client last received it. However, evidence-based practice indicates that the nurse should take a different action first. -It is important for the nurse to measure the client's vital signs to assess the client's overall status; however, evidence-based practice indicates that the nurse should take a different action first -Whenever a client reports pain, nonpharmacologic comfort measures might help; however, evidence-based practice indicates that the nurse should take a different action first.
a nurse is caring for a group of clients on a mental health unit. Which of the following should the nurse recognize as a maladaptive defense mechanism? a- a client slams a drawer after misplacing her wallet b- a man buys his partner a gift after flirting with his secretary c- a client forgets to schedule needed appointments when fearing chemotherapy d- a client ignores the thought of pain when scheduled for oral surgery
c- repression occurs when a person deals with anxiety by unconsciously putting the unacceptable/ stressful thought out of their mind.This is considered maladaptive because it is interfering with healthy functioning aka not getting chemo
A nurse in a LTC facility is caring for a client who has late stage Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? a- Post a written schedule of daily activities. b- Use an overhead loudspeaker to announce events. c- Provide a consistent daily routine. d-Allow the client to choose free-time activities.
c-A consistent daily routine is appropriate for the care of a client who has Alzheimer's disease. -Picture symbols, rather than written schedules, are appropriate for the care of a client who has Alzheimer's disease. -Personal communication with a low voice, rather than a loudspeaker, is appropriate for the care of a client who has Alzheimer's disease. -Providing the client with choices can increase client anxiety and is therefore not appropriate for the care of a client who has Alzheimer's disease.
A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i am going to do. I cannot even think right now". Which of the following actions should the nurse take? A-Identify other housing options and sources of transportation B- notify the facility chaplain to request scheduling an appointment c- confirm that everything will be alright because belongings can be replaced d-maintain eye contact with client and summarize the client's feelings
d- this demonstrates therapeutic communication. during the initial interview, it is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available. Maintaining eye contact demonstrates support, empathy, and advocacy. - do not offer false hope, instead focus on the feelings of the client and his unique response to the crisis -you should help the client identify sources of support ( do not do it for them or presume what is best - it can be overwhelming to the client to think about housing and transportation and they are immediate needs but right now the nurse should focus on the feelings of the client
A nurse is caring for a client who has dementia die to AD and was admitted to a LTC 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? a- This is where you live now." b- "This is a safer place for you to live." c- "Tell me what you like to cook for dinner." d-"Your family said there is no one to care for you at home."
c-Alzheimer's disease is a progressive cognitive disorder. Dementia due to Alzheimer's disease means that the client is experiencing later stages of the illness with moderately severe to severe cognitive decline. By asking the client to talk about what she likes to cook for dinner, the nurse is demonstrating validation therapy by asking the client to talk about the areas that concern her. The nurse could continue the conversation by discussing how much the client misses her home and partner. Validation therapy helps clients who have cognitive disorders discuss their feelings about past events and people. -By telling the client that this is where she lives now, the nurse does not address the verbalized feelings of the client and might cause the client's behavior to become combative. Although this may be true, a client who has dementia due to Alzheimer's disease experiences moderately severe cognitive decline and might not understand or agree with the statement. This statement does not reflect empathy or support toward the client. The statement does not foster open communication, but rather blocks communication. -This statement is not therapeutic and may suggest to the client that his family has abandoned him. This statement creates a barrier in communication and trust toward family and staff.
The family of an older client bring him to the emergency room after finding him wandering outside. During initial assessment , the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. which of the following factors should the nurse identify as a likely explanation for the client's behavior? A-He is hard of hearing. B-Pain C-Confusion D-Language barrier
c-Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion. -If the client cannot hear the nurse, he would most likely communicate that. -Clients who have pain can usually still provide assessment data. -Even if the client speaks a different language as the nurse, the family accompanied him. Although the nurse should use a medical interpreter, the family should be able to provide some initial explanations of the facts leading to the visit.
A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client? a- A room adjacent to the nursing station b- A room without a window c- A room with dim lighting d-A room containing personal belongings
d-A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment. -Clients who have impaired cognition are often disoriented. A room with dim lighting might not maximize environmental clues for the client. -Clients who have impaired cognition need a low-stimulation environment. A room adjacent to the nursing station might provide too much stimulation for this client. -Clients who have impaired cognition are often disoriented and cannot distinguish between night and day. A room without a window may contribute to the disorientation.
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? a-Decreased auditory and visual acuity b-Decreased display of emotions c-Personality traits that are opposite of original traits d-Forgetfulness gradually progressing to disorientation
d-Dementia usually appears first as forgetfulness. Other manifestations may be apparent only upon neurologic examination or cognitive testing. Loss of functioning progresses slowly from impaired language skills and difficulty with ordinary daily activities to severe memory loss and complete disorientation with withdrawal from social interaction. -The nurse should instruct the family to expect the client to demonstrate an exaggeration of previous personality traits. -The nurse should tell the family to expect the client to be unable to control emotions and behavior, and be more likely to exhibit emotional outbursts. -Dementia is not known to affect auditory and visual senses. The nurse should instruct the family to expect the client's reasoning and logic skills to decline.
a nurse on a LTC 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? A-Rotate assignment of daily caregivers. B-Provide an activity schedule that changes from day to day. C-Limit time for the client to perform activities. D-Talk the client through tasks one step at a time.
d-The nurse should plan to talk the client through tasks one step at a time to minimize confusion and promote independence, which will decrease the client's anxiety level. -The nurse should allow plenty of time for the client to perform activities to increase comfort and decrease the client's anxiety level. -The nurse should provide a structured schedule of activities that does not change from day to day to decrease the client's confusion. -The nurse should assign the same staff whenever possible to care for the client to minimize confusion and ensure continuity of care for the client.