ATI modules (Exam 2)

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

"I should increase my protein intake."

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should report pain at my wound site".

A nurse is caring for a client who states, "My doctor said I should have and EMG (electromyograph). What is that?" Which fo the following responses should the nurse make? - "It is a test that determines if there is a loss of the ability to smell." - "It is a test that measures the response of the eardrum to various sounds." - "It is a test that determines if there is nerve damage affecting a muscle." - "It is a test that is performed to diagnose damage to the retina of the eye."

"It is a test that determines if there is nerve damage affecting a muscle." An EMG, or electromyography, is performed to determine if there is damage to the nerves leading to the muscles. During an EMG, very small needles are inserted into a muscle. The needles are attached by a wire to an EMG machine that records the electrical activity in the muscle. Damage to a nerve will alter this electrical activity.

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

"This type of healing begins in the wound bed with the generation of granulation tissue".

A nurse is caring for a client who is scheduled for an otoacoustic emission (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make? - "You will have small electrodes placed on your scalp during the test." - "You will have a small probe placed in your ear canal during the test." - "You will have dye injected through an IV during the test." - "You will have photographs taken using a special camera during the test."

"You will have a small probe placed in your ear canal during the test." During an OAE test, a small probe is placed in the auditory canal. A series of sounds are played through the probe, which then measures the returned echo.

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? SATA - A walking cane - Area rugs - A walker - Audio materials - A magnifying glass

- A walking cane - A walker

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? SATA - Speaks in soft tones - Reports ringing in the ears - Asks for questions to be repeated - Withdraws from social activities - Reports feeling dizzy at times - Describes sounds as being muffled

- Asks for questions to be repeated - Withdraws from social activities - Describes sounds as being muffled

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? SATA - Difficulty maintaining attention - Aphasia - Agitation - Alertness - Hallucinations - Rambling speech

- Difficulty maintaining attention - Agitation - Hallucinations - Rambling speech

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

Hydrogel

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Increased blood glucose

A nurse is proving care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client? - Keep the client's environment free from clutter. - Offer opportunities for the client to get exercise. - Prevent the client's social isolation. - Provide nutritional education to the client.

Keep the client's environment free from clutter. The client's sensory deficit indicates that they might be at risk for injury. Therefore, the priority action for the nurse is to maintain the client's safety. Keeping the client's environment free from clutter can reduce the client's risk of falls.

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?

The AP places the client in high-Fowler's position

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

The skin assists in the regulation of body temperature

A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

The skin of older adults is thinner and has less subcutaneous padding over bony prominences

A nurse is planning care for an older adult clients who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Tilt the client on their side at 30 degrees

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII? - Monitor for symmetry when the client shrugs their shoulders. - Ask the client to identify a smell in each nostril. - Have the client stick out their tongue. - Whisper something in one ear while occluding the other ear.

Whisper something in one ear while occluding the other ear. Cranial nerve VIII is the vestibulocochlear, or auditory, nerve, which has functions for both hearing and balance. To assess hearing, the nurse occludes one year then whispers a word or short phrase behind the client's head. The nurse then assesses the opposite ear.

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?

You should shift your weight off your buttocks at intervals throughout the day

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

Your staples will be removed in about 2 weeks

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make? - "SPD occurs when a client's brain is unable to process rapidly occurring multiple stimuli." - "SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin." - "A client is diagnosed with SPD if they experience significant decrease in stimuli." - "A client who has SPD has a deficit in the function of one or more of their five senses."

"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin." SPD is a sensory disorder in which a client experiences a hypersensitive response to normal stimuli, such as the sound of a television, or the feel of fabric on their skin.

A nurse is reviewing the process of how a refraction assessment is preformed with a client. Which of the following statements should the nurse make? - "This test is performed using the Snellen chart." - "This test is performed using lenses of various prescription strengths." - "This test is performed by injecting dye into a vein." - "This test is performed by measuring the amount of pressure inside the eyes."

"This test is performed using lenses of various prescription strengths." A refraction assessment is performed on each eye using either a computerized refractometer or via a manual assessment using lenses of various prescription strengths.

A nurse is providing teaching for a client who has a prescription for alginate dressing for a wound. Which of the following statements by the client indicates an understanding of alginate dressing?

"This type of dressing will need a secondary dressing for reinforcement".

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? SATA - Provide the client with large print materials. - Ensure the client wears their hearing aids. - Use a sign language interpreter. - Communicate using paper and pen. - Face the client when speaking.

- Ensure the client wears their hearing aids. - Use a sign language interpreter. - Communicate using paper and pen. - Face the client when speaking.

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? SATA - Inspect the feet every day. - Wear closed-toe shoes. - Install smoke detectors in the home. - Manage glucose levels. - Encourage the client to take their time when speaking.

- Inspect the feet every day. - Wear closed-toe shoes. - Manage glucose levels.

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? SATA - Loop diuretics - Benzodiazepines - NSAIDS - Antihistamines - Aminoglycoside antibiotics

- Loop diuretics - NSAIDS - Aminoglycoside antibiotics

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following decreases with age? SATA - Sweet - Sour - Spicy - Bitter - Salty - Savory

- Sour - Bitter - Salty

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? SATA - Trauma to the outer ear - Damage to inner ear structures - Inflammation - Down syndrome - Cerumen buildup - Otitis media

- Trauma to the outer ear - Inflammation - Cerumen buildup - Otitis media

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following informations should the nurse include? - An electromyography (EMG) test is performed by placing small electrodes on the scalp. - A fluorescein angiography test diagnoses dysfunction of the cochlea. - A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles. - An Amsler grid test is performed by looking at the internal eye using a slit lamp.

A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles. A bone oscillator test measures how well vibrations are transmitted through the ossicles (malleus, incus, stapes) of the ear.

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is incontinent and taking a prescribed diuretic

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

A clients who has a Braden scale score of 9

A nurse is caring for a client who has dime-sized stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use?

A transparent film

A charge nurse is discussing hearing test with a newly licensed nurse. Which of the following information should the charge nurse include? - The audiometer test measures the brain's electrical activity in response to sounds. - A tuning fork is placed against the client's mastoid bone during the Rinne test. - The otoacoustic stimulation (OAE) test is the most commonly performed hearing test. - Small electrodes are placed behind the client's ears during an electromyography test.

A tuning fork is placed against the client's mastoid bone during the Rinne test. The Rinne test is performed when a tuning fork is struck and placed against the mastoid bone. The client identifies when they can no longer hear any sound. The tuning fork is then placed 1-2 cm away from the ear and the client identifies if they can still hear the sound.

The nurse is reviewing the medical record of a client who reports recent insomnia. The nurse should identify which of the following conditions as a risk factor for developing insomnia? - Gastroesophageal reflux disease - Herniated lumbar disc - Wernicke's aphasia - Alzheimer's disease

Alzheimer's disease. Neurologic conditions can lead to anosmia, or a loss of the sense of smell. This includes conditions such as Alzheimer's disease or Parkinson's disease.

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions? - Availability of aids to enhance vision - Antibiotic therapy - Risks associated with the loss of peripheral vision - Treatment options

Availability of aids to enhance vision. Clients who have impaired or low vision from age-related macular degeneration can benefit from the use of large print material or a magnifying glass. Adequate lighting in the client's environment can also enhance vision.

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II? - Check the client's visual acuity using a Snellen chart - Have the client identify a specific smell. - Whisper on one of the client's ear while occluding the other. - Observe for facial symmetry while the client smiles.

Check the client's visual acuity using a Snellen chart. Cranial nerve II is the optic nerve, which provides the sensory function for vision. The nurse should assess the cranial nerve by checking the client's visual acuity and visual fields.

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9% sodium chloride

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and call for help. Which of the following actions should the nurse take?

Cover the client's wound with a sterile saline dressing

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

A nurse is caring for a 6-month old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?

Dermatitis

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia? - Rapid-onset memory loss - Hyperglycemia - Hypervigilance - Difficulty problem solving

Difficulty problem solving. Difficulty with problem-solving is an expected manifestation of dementia. Dementia is non-reversible, but the nurse can help the family develop strategies to manage the client's condition.

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Empty and measure the drainage

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

Flex the client's knees while in bed

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments? - Diabetic retinopathy - Macular degeneration - Cataract - Glaucoma

Glaucoma Glaucoma results in an increase in intraocular pressure and can cause loss of vision.

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes? - Decreased sense of touch - Hearing loss - Impaired ability to smell - Reduced taste

Hearing loss Hearing and vision are the two most commonly affected senses with aging.

A nurse is caring for a middle-adult client who asks about expected age-related changes. Which fo the following sensory changes should the nurse include as age-related change? - Presbyopia - Diplopia - Myopia - Astigmatism

Presbyopia. Presbyopia is the decrease in the ability to focus clearly on objects that are up close. Presbyopia typically begins during middle adulthood due to a loss of flexibility of the lens of the eye.

A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

Pressure injury documentation includes location, stage, measurements and condition of the wound bed and any drainage present

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation? - Sensory deprivation is commonly experienced by clients who are in the ICU. - Sensory deprivation can cause tactile stimuli to feel painful. - Risk factors for sensory deprivation include experiencing total vision or hearing loss. - Sensory deprivation occurs most often in children who have developmental disorders.

Risk factors for sensory deprivation include experiencing total vision or hearing loss.