NURS 1200 WK 3 ATI

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

""Have your had a recent influenza infection?" The cause of GBS is unknown, but it usually follows a viral infection.

A nurse is conducting a health promotion class for clients and their children about sun protection. The nurse should identify which of the following client responses as an indication the the teach ing was effective?

"I will avoid sitting in the sun between 10a.m. and 3 p.m." - The client should avoid sitting in the sun between the hours of 1000 and 1300, the time of day during which maximum exposure can occur.

A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse make?

"The intra-articular deposition of urate crystals causes inflammation. - Gout, our gouty arthritis, develops when urate crystals deposit in joints and tissues and cause inflammation and pain

A nurse is teaching a group of older adults about health tests and screenings. Which of the following information should the nurse include? (Select all that apply)

"You should have a single dose of the shingles vaccine at age 60." - Older adult clients, starting at age 60, should have a single dose of the herpes zoster vaccine. "You should have the pneumococcal vaccine at age 65 and then every 10" "You should ahve visual acuity screening every year"

A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?

"restrict lifting objects greater than 10 pounds" - The nurse should instruct the client to restrict lifting objects greater than 10 lb to reduce the risk for increased intraocular pressure.

A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?

1 cup milk - milk contains the most calcium per serving. Milk contains 276 mg calcium per one cup serving.

A nurse is providing teaching about nutrition to a group of clients. The nurse should include that which of the following foods contains the highest level of thiamine per serving?

1 cup whole grain wheat flour. - Whole or enriched grains contain 0.981 mg thiamine, which is the highest level of thiamine.

A nurse is teaching a group o adults about nutrition. The nurse should include which of the following amount as an appropriate daily intake of fiber for adult women?

20 - 35 g

A nurse is providing health promotion teaching to the parent's of an infant. Which of the following conditions should the nurse identify as the leading cause of death among this age group?

Congenital anomalies - are the leading cause of infant mortality in the U.S.

A nurse is instructing a group of clients about nutrition. The nurse's teaching plan should state that in order to limit saturated fat intake, the client should limit total fat intake to what percentage of total calories per day?

30% - In order to limit saturated fat intake, the total percentage of fat intake per day is 35%.

A nurse is reviewing the medication history of a client who has a new prescription for colchicine Which of the following medications increases the client's risk when used in combination with colchicine for developing rhabdomyolysis?

Atorvastatin - Atorvastatin can cause rhabdomyolysis. When the client takes both these medications, the risk of developing this adverse effect is increased.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply)

Contractures of the extremities - are a complication of immobility because of disuse of muscles and joints. Polyuria is incorrect. Polyuria is not a finding in clients who are immobile. Crackles in the lungs - are a complication of immobility, due to mucus that collects in the dependent airways. The client often cannot cough effectively and oxygenation status declines. Pressure ulcers - are a complication of immobility, due to increased pressure on skin and bony prominences, which affects tissue metabolism.

A nurse is assessing a client who has Paget's disease of the bone. Which of the following findings should the nurse expect? (Select all that apply)

Cranial enlargement. - when the skull is involved, Paget's disease causes thickening and enlargement of the skull bones and enlargement of the cranium. Skeletal pain. - paget's disease causes pain and tenderness over the affected bones. Abnormal gait - when the legs are involved, Paget's disease causes bowing of the legs and an abnormal gait.

A nurse is assessing a client who has a rotator cuff injury. Which of the following should the nurse expect?

Difficulty with abduction of the arm at the shoulder. - A client who has a rotator cuff injury has shoulder pain and difficulty with abduction of the arm at the shoulder.

A nurse in a provider's office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury?

Inability to abduct the arm at the shoulder.

A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. which of the following tests should the nurse request the client perform?

Hold the wrist at a 90-degree flexion - Carpal tunnel syndrome is the compression of the median nerve at the wrist. The condition is common in people who perform repetitive motions of the hand and wrist, such as typing. Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at a 90-degree flexion will usually result in numbness, tingling, or weakness.

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Place suction equipment at the client's bedside - Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.

A nurse is a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?

Positive Phalen's sign - If a client who has carpal tunnel syndrome holds his wrist in flexion for 60 seconds, it will produce tingling and numbness over the median nerve, the palmar surface of the thumb, the index finger, the middle finger, and part of the ring finger. This is a positive Phalen's test.

A nurse is assisting with routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?

Scoliosis is an abnormal lateral curvature of the spine that typically observed in children over the age of 10 years. Mild scoliosis usually has few consequences, but more severe curvature can restrict lung function.

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray?

Skim milk (Full liquids include milk and milk products, so the client may now ask for skim milk. All other options are a liquid diet.)

A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following foods is a good source of high-quality protein?

Soybeans -The nurse should instruct that soybeans and soybean products are high-quality, or complete, sources of proteins. Complete proteins contain all nine essential amino acids required for growth and maintenance of the body.

A nurse is teaching a client who has chronic tophaceous gout about his new prescription for allopurinol. The nurse should explain that the purpose of this medication is to reduce blood levels of which of the following substances?

Uric acid - Hyperuricemia is the underlying cause of gout. Clients who have chronic gout develop tophi. The purpose of allopurinol is to reduce the synthesis of uric acid.

A nurse is talking with a client who is beginning a program of moderate exercise. The client asks the nurse why warm-up exercises are necessary. which of the following responses should the nurse make?

Warm-up exercises reduce the risk of injury. - a warm-up period before exercising helps reduce the risk for musculoskeletal injuries, such as ligamentous sprains and muscular strains, and prepares the body for upcoming activities. Stretching increases flexibility ad lessens the risk of uncoordinated movement.

A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client that which of the following beverages can trigger an attack?

alcohol

A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take (Select all that apply)

encourage rest - Elevation reduces edema, which helps to relieve pain. elevate the ankle - Elevation reduces edema, which helps to relieve pain. place compression bandage - Elevation reduces edema, which helps to relieve pain.