ATI Modules for Exam 3 (213)

A nurse is conducting an educational session for clients who report experiencing stress-related disorders. A client asks the nurse which part of the body activates the stress response. Which of the following responses should the nurse provide?

Hypothalamus

A nurse is meeting with a client who is recovering from a bilateral mastectomy. Since being discharged, the client has changed dressings as prescribed and completed arm exercises. The client tells the nurse, "I'm pleased with my postoperative progress." The nurse should identify that the client is displaying which of the following self-concept characteristics?

Self-efficacy

A nurse is caring for a client who has a history if migranes. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the client's migraines? (Select all that apply) Sleep-wake homeostasis Sensory overlad Sleep deprivation Increased melatonin Decreased hypocretin levels

Sensory overload Sleep deprivation

A nurse is caring for a group of client who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk? (Select all the apply) Uncircumcised infants School-age children Middle adults Older adults Young adults

Uncircumcised infants School-age children Older adults

A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urine. Which of the following urinary diversions should the nurse anticipate the client will need?

Ureteral stent

A nurse is planning care for a client who reports blood in their stool. Which of the following tests should the nurse anticipate the provider ordering?

Fecal occult blood test

A nurse is caring for a client who has delivered a healthy newborn. The client is tense, refuses to hold the baby, and tells the nurse, "I have no idea how to handle having a baby. I wish this pregnancy had never happened." Which of the following statements should the nurse make?

"Becoming a parent is a new experience for you. Let's talk about your concerns."

A nurse is meeting with a client who was recently diagnosed with rheumatoid arthritis. The client tells the nurse, "I'm never going to be able to do anything fun." Which of the following questions should the nurse ask to assess the client's identity?

"How do others' opinions impact the way you see yourself?"

A nurse is assessing the self-concept of a client who recently lost their job and, as a result, might lose their home to foreclosure. Which of the following questions should the nurse ask the client when gathering information regarding self-concept?

"How would you describe yourself and your situation?"

A nurse in a community clinic is interviewing a client who is distressed and reports being unable to sleep following a neighborhood fire several days ago. The client has hypertension, tachycardia, and is diaphoretic. The nurse should identify that the client is experiencing which of the following types of stress?

Acute stress

A nurse is interviewing a client who recently experienced an act of workplace violence when an armed person held the workers at gunpoint before police intervened. The client now reports being anxious and fears the gunman might return. The nurse should identify that the client is experiencing which of the following types of crisis?

Adventitious

A nurse in a health clinic is interviewing a client who is upset and reports that their stress "is too much to handle." The client is unemployed, a single guardian to young children, and has periodic asthma attacks. Which of the following stress-related conditions is the client experiencing?

Allostatic load

A nurse is caring for a client who is 4 days postoperative following a below-the-knee amputation related to a work injury. The nurse should identify that which of the following are components of the client's self-concept that this injury can impact? (Select all that apply.)

Body image Role performance Identity Self-esteem

A nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding?

Consuming alcohol

A nurse is reinforcing teaching with a client about diagnostic urinary testing. Which of the following should the nurse recognize is consistent with cystometric testing?

Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins

A nurse is caring for a client who has pancreatic cancer that is unresponsive to treatment. The client is experiencing significant weight loss and fatigue, but when the nurse asks how they are feeling, they respond with, "Great! I'm going to beat this cancer." Which of the following defense mechanisms is the client using?

Denial

A nurse is caring for a client with suspected dehydration. For which of the following findings should the nurse monitor this client?

Dry mucous membranes

A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for?

Hernia

A nurse is caring for a client who reports experiencing stress over an upcoming surgical procedure. Which of the following statements describes the characteristics of stress?

Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one's state of equilibrium.

A nurse is caring for a client who reports that they use their phone at night while they are in bed. The nurse should identify that excessive smartphone use can increase the client's risk for which of the following? a. Depression b. Binge eating disorder c. Restless leg syndrome (RLS) d. Diminished circadian rhythm

a. Depression

An employee health nurse is providing teaching about sleep promotion to a group of newly licensed nurses. Which of the following statements should the nurse include? a. "Taking a cool shower before bedtime can help with sleep" b. "If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music." c. "To promote nighttime sleep, limit daytime naps to 1 hour" d. "Exercising 1 hour before bedtime can help promote relaxation and sleep"

b. "If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music."

A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which of the following findings should the nurse identify as a risk factor for obstructive sleep apnea? a. Hypersomnia b. Obesity c. Active glossal muscle d. History of tonsillectomy

b. Obesity

A nurse is caring for an older adult client who is having difficulty sleeping and has a new prescription for a medication to help them sleep. Which of the following medications should the nurse identify as a first-line sleep aid for older adults? a. Alprazolam b. Eszopiclone c. Controlled-release melatonin d. Diphenhydramine

c. Controlled-release melatonin

A nurse is caring for a client who has a new prescription for a nonbenzodiazepine hypnotic to promote sleep. For which of the following adverse effects should the nurse monitor the client? a. Retrograde amnesia b. Urinary discomfort c. Dry mouth d. Hallucinations

d. Hallucinations

A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body.

The large intestine

A nurse is caring for a college student admitted for acute alcohol intoxication. The client reports feeling overwhelmed and expresses an inability to cope with stressors at school. Which of the following statements should the nurse make?

"Let's talk about the coping methods that have worked for you in the past."

A nurse is caring for a client who has migraine headaches and reports that they are "getting worse." Which of the following questions should the nurse ask the client to determine if the headaches are a stress-related disorder? (Select all that apply.)

"What is the intensity of your migraine headaches?" "How often do the migraine headaches occur?" "What type of support is available to you when you have a migraine headache?" "What coping strategies do you use when you experience a migraine headache?" MY ANSWER

A nurse is interviewing a client who is in distress and tells the nurse, "My ex-partner is suing for full custody of my children. I am so worried and don't know what to do." Which of the following questions should the nurse ask to evaluate the client's coping skills?

"What strategies have you used in the past to deal with stress?"

A nurse is reinforcing teaching with a newly licensed nurse about urinary retention. Which of the following clients should the nurse include as having an increased risk for this condition?

A client who has an enlarged prostate

A nurse is reinforcing teaching for a client who has an ileostomy. The nurse should identify that which of the following is true regarding an ileostomy?

An ileostomy can allow the colon time to heal from surgery

A nurse is caring for a client who is in crisis following the breakup of a long-term relationship. The client tells the nurse, "I might as well just die. My life is over." Which of the following actions should the nurse take first?

Conduct a suicidal risk evaluation.

A nurse is caring for a client who has a history of irritable bowel syndrome and report that their last bowel movement was 5 days ago. The nurse should identify this is which of the following types of altered elimination pattern?

Constipation

A nurse is caring for an older adult client who reports being stressed about their health status due to problems with short-term memory, slower reaction times when driving, and urinary frequency. The nurse should recognize that the client is experiencing which of the following types of stressors?

Developmental stressors

A nurse is preparing to collect a urine sample for urinalysis a reagent strip. The nurse should identify that the reagent strip can detect substances that are consistent with which of the following conditions?

Diabetes

A nurse is reviewing factors that can affect a client's self-concept. The nurse should identify that empathy, motivation, and self-awareness are domains of which of the following factors?

Emotional intelligence

A nurse is reviewing the plan of care for a client who was recently divorced. Which of the following interventions should the nurse include to promote the client's positive self-concept? (Select all that apply.)

Encourage the client to identify past and current accomplishments. Encourage the client to verbalize perceptions that indicate a healthy self-esteem. Assist the client to identify healthy coping strategies and support systems. Collaborate with the client, family, and members of the health care team to ensure successful implementation of the plan of care.

A nurse is preparing to insert a nasogastric tube into a client for decompression. Which of the following actions should the nurse perform first?

Ensure client is in a sitting position

A nurse is caring for a client who has delivered a healthy newborn. The client tells the nurse that while they are somewhat stressed about being a new parent, they are thrilled by the birth of their child. The nurse should identify that the client is experiencing which of the following types of stress?

Eustress

A nurse is assessing a client who is working at home due to COVID-19 restrictions. The client reports abdominal cramping and bloating with diarrhea and states, "I am completely stressed out from working at home." The nurse should identify that the client is experiencing manifestations of which of the following stress-related conditions?

Irritable bowel syndrome

A nurse is caring for an adolescent client who plans to attend the same law school their parent attended and work at their parent's law firm upon graduation. The client has never questioned their academic and career pathway and states, "If it's good enough for my parent, it's good enough for me." The nurse should identify that which of the following identity statuses describes the client's position?

Foreclosure

A nurse is caring for a client who has constipation. Which of the following diets should the nurse encourage the client to follow?

High fiber

A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors? (Select all that apply.)

History of frequent respiratory infections Consumes large amounts of dairy in their diet Currently taking cephalexin for pneumonia

A nurse is caring for a client whose partner was recently hospitalized with COVID-19. The client is experiencing manifestations related to the alarm stage of general adaptation syndrome (GAS). For which of the following manifestations should the nurse monitor? (Select all that apply.)

Hypertension Dilated pupils Increased state of arousal

A nurse is providing information to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statements by the client indicates an understanding of the information?

I can develop a kidney infection called pyelonephritis

A nurse is caring for a female client who has a prescription for a clean catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to provide a urine specimen?

I need to wipe from front to back with a sanitary wipe

A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution?

Instruct the client to lie on their left side with their right leg pulled up to their chest

A nurse is caring for a client who reports enjoying retirement because they are reading more, visiting with children and grandchildren, and playing bridge with their friends. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development?

Integrity vs. despair

A nurse is reinforcing teaching with a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse identify will help facilitate urinary elimination for this client?

Intermittent catheter

A nurse is assessing a client who was sexually assaulted 6 months ago and has been diagnosed with post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect? (Select all that apply.)

Intrusive memories of the event Flashbacks of the event Exaggerated startle response when reminded of the event

A nurse is meeting with a client at a community health center to assess their self-concept. Which of the following factors should the nurse consider during the assessment? (Select all that apply.)

Life experiences Societal and cultural attitudes Health status Academic achievement

A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence?

Loss of bladder tone

A nurse is reviewing a client's list of medications and supplements. Which of the following medication classifications increases the risk of constipation?

Narcotic pain medications

A nurse is reinforcing teaching with a client about foods that can irritate the bladder. Which of the following foods should the nurse identify as being a bladder irritant?

Oranges

A nurse is collecting data from a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings?

Pale yellow, clear urine

A nurse is providing discharge teaching about health promotion to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply).

Practice mindful breathing. Start each day with a to-do list. Develop habits to mitigate stress.

A nurse is talking about implementing self-care strategies to cope with the stress of caregiving with the partner of a client who has dementia. Which of the following strategies reported by the partner should the nurse identify as an example of effective coping?

Practicing deep breathing while sitting outside

A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function?

Preform colostomy irrigation

A nurse is caring for a client who has been charged with partner violence against their spouse. The client is angry, pacing, and yells out, "I wouldn't lose my temper if my spouse would just leave me alone. It's their fault." The nurse should identify the client is displaying which of the following defense mechanisms?

Projection

A nurse is interviewing a client to assess their self-concept and asks, "What are some of the accomplishments that make you feel good about yourself?" The nurse is assessing which of the following components of self-concept?

Self-esteem

A nurse is planning care for a client who is recently divorced with two young children. The client reports difficulty sleeping, feeling hopeless, and being estranged from family. The nurse should plan to monitor the client for which of the following potential manifestations of chronic stress

Suicide

A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause of the diarrhea?

The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow

A nurse is caring for a client who is establishing a bladder training program. Which of the following indicates that the bladder training is successful?

The client has less than one urinary accident per week

A nurse is reinforcing instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements should the nurse identify is true regarding a nephrostomy tube?

The tube is temporary

A nurse is reviewing the primary function of they urinary tract with a group of newly licensed nurses. Which of the following information should the nurse include?

The urinary tract eliminates waste and excess fluid from the body

A nurse is planning care for a client who has an order for urinalysis. Which of the following tests should the nurse anticipate being ordered if the presence of white blood cells is detected on urinalysis?

Urine culture

A nurse is collecting data from a client who has stress incontinence. Which of the following findings should the nurse expect with this client?

Urine leakage following coughing

A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea? a. "common causes of central sleep apnea are opioid overdose and congestive heart failure." b. "Central sleep apnea is caused by obesity and an inactive tongue" c. "Central sleep apnea is easily diagnosed using polysomnography" d. "Central sleep apnea is related to the recurrent episodes of upper airway collapse and obstruction"

a. "common causes of central sleep apnea are opioid overdose and congestive heart failure."

A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions? a. Diabetes mellitus b. Central sleep apnea c. Hypersomnia d. Restless leg syndrome (RLS)

a. Diabetes mellitus

A nurse is planning care for a client who is postoperative. Which of the following interventions should the nurse plan to include to promote emotional comfort for the client? a. Encourage the client to verbalize their needs and concerns. b. Limit time spent with client. c. Ask the client to splint the incision when coughing. d. Administer pain medications as prescribed.

a. Encourage the client to verbalize their needs and concerns.

A nurse is contributing to a presentation about hypersomnia. Which of the following information should the nurse recommend including in the presentation? a. Hypersomnia does not improve with increased sleep. b. Hypersomina is associated with a disturbed circadian rhythm. c. Clients who experience hypersomnia have a longer attention span. d. Clients who experience hypersomnia lack the hormone hypocretin.

a. Hypersomnia does not improve with increased sleep.

A nurse is caring for a client who has narcolepsy (Nt1) with cataplexy. The nurse should identify that this condition is caused by a lack of which of the following hormones? a. Hypocretin b Melatonin c. Estrogen d. Insulin

a. Hypocretin

A nurse is caring for a client who was admitted following a report of lumbar pain. In addition to administering pain medications, which of the following interventions should the nurse implement to promote comfort? a. Present information honestly b. Have another nurse present difficult information c. Do not include the client's concerns in the plan of care if they interfere with treatment. d. Preform cognitive behavioral therapy with the client.

a. Present information honestly

A nurse is reviewing the concept of comfort with an assistive personal (AP). Which of the following statements by the AP indicates an understanding of comfort? a. "Providing comfort for a client is achieved by the relief of physical pain through the administration of medication" b. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy." c. "Providing comfort for a client is achieved by taking control of the clients care and creating routines for the client to become familiar with." d. "Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing"

b. "Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy."

A nurse manager is conducting an in-service about the physiological functions of sleep for a group of staff nurses. Which of the following statements by one of the nurses indicates an understanding of the teaching? a. "Sleep is a process that decreases the development of new neural pathways that assist with retention of knowledge and memorization" b. "The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake." c. "The circadian rhythm is an external process that controls the sleep-wake cycle." d. "Clients experience the highest quality sleep when they complete three out of the four stages of sleep."

b. "The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake."

A nurse is reviewing the plan of care for a client who was admitted with insomnia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further weight gain for the client? a. Increased ghrelin production b. Increased leptin production c. Decreased hypocretin levels d. Decreased melatonin levels

b. Increased leptin production

A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the Brian transmits the sensory data that is used to develop dreams? a. Hypothalamus b. Thalamus c. Cerebral cortex d. Pineal gland

b. Thalamus

A nurse is assessing a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions? a. Hypersomnia b. Narcolepsy (NT2) c. Narcolepsy (NT1) d. Insomnia

c. Narcolepsy (NT1)

A nurse is contributing to a presentation about non pharmacological interventions used to promote sleep. Which of the following information should the nurse recommend including in the presentation? a. Non pharmacological interventions should only be practiced in the clients home setting. b. Massage is a non pharmacological intervention that should be used to promote sleep for clients who are taking anticoagulants. c. Non-pharmacological interventions used to help promote sleep include acupuncture and thermotherapy. d. Before implementing nonpharmalogical interventions, clients should be evaluated by a sleep specialist for sleep apnea and chronic lung disease.

c. Non-pharmacological interventions used to help promote sleep include acupuncture and thermotherapy.

A nurse is discussing the stages of the sleep cycle with a client. The nurse should include that the immune system is strengthened and tissues and bones are repaired during which of the following stages of the sleep cycle? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

c. Stage 3

A nurse is caring for a client who needs to be awakened for the administration of an oral medication. Which of the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle when awakened? a. The client was easily awakened. b. The client states that they were having a pleasant dream. c. The client experiences mental cloudiness for 30 to 60 min. d. Prior to being awakened, the clients breathing was irregular and their heart rate was elevated

c. The client experiences mental cloudiness for 30 to 60 min.

A nurse is evaluating a client after measures to promote comfort have been implemented. Which of the following statements by the client indicates that the client has been comforted? a. "I wish the staff would listen closer to my needs." b. "I am concerned about what is going to happen during my test tomorrow." c. "It seems to take the staff a while to wander the call light." d. "My health care team has helped me to feel safe during my stay"

d. "My health care team has helped me to feel safe during my stay"

A nurse is caring for a client who is having difficulty falling asleep. Which of the following interventions should the nurse implement to promote sleep for the client? a. Offer the client a caffeinated beverage 3 hours before their bedtime. Turn on the clients television before they go to bed. b. Turn on the clients television before they go to bed. c. Warm the temperature of the clients room before they go to bed. d. Dim the lights in the client's room at bedtime

d. Dim the lights in the client's room at bedtime

A nurse is caring for an older adult client who reports that they wake up frequently during the night. The nurse should identify that which of the following is a characteristic of older adult sleep patterns that might explain the client's frequent awakenings? a. Older adults tend to spend more time in stage 4 sleep. b. Older adults tend to spend more time in stage 3 sleep. c. Older adults tend to spend more time in stage 1 sleep. d. Older adults tend to spend more time in stage 2 sleep.

d. Older adults tend to spend more time in stage 2 sleep.

A nurse is caring for a client who takes an over-the-counter (OTC) sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effect of OTC sleep aid medications? a. Hyperactivity b. Diarrhea c. Excessive salivation d. Urinary retention

d. Urinary retention