Custom: ATI assessment A Medical surgical II (April 3/23)

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Hypotension Tachycardia Irritability Tinnitus

Irritability The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.

A nurse is planning nutritional teaching for a client who is experiencing fatigue due to iron deficiency anemia. Which of the following foods should the nurse recommend to the client? 1.5 oz raisins 8 oz black tea 1 cup canned black beans 8 oz whole milk

1 cup canned black beans The nurse should recommend canned black beans as they contain the greatest amount of iron at 4.56 mg per serving.

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following? 2 hr 6 hr 8 hr 4 hr

4 hr MY ANSWER The nurse should infuse the packed RBCs for no longer than 4 hr due to temperature inconsistencies that develop over time and the possibility of bacterial contamination.

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching? Aplastic anemia is associated with a decreased intake of iron. Aplastic anemia results in an increased rate of RBC destruction. Aplastic anemia results in an inability to absorb vitamin B12. Aplastic anemia results from decreased bone marrow production of RBCs.

Aplastic anemia results from decreased bone marrow production of RBCs. Aplastic anemia is a hypoproliferative anemia resulting from decreased production of RBC within the bone marrow.

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect? Pruritus Hypertension Bradykinesia Xerostomia

Bradykinesia The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following? Prolonged bleeding Cellular hypoxia Impaired immunity Fluid retention

Cellular hypoxia The client's laboratory results indicate anemia, which places the client at risk for cellular hypoxia.

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 As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? Transient ischemic attack (TIA) Hemorrhagic stroke Thrombotic stroke Embolic stroke

Hemorrhagic stroke A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. Place a pillow under the client's head. Gently restrain the client's extremities. Apply a face mask for oxygen administration.

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests? Sweat test Haptoglobin Antinuclear antibodies Schilling test

Schilling test The Schilling test helps determine the cause of vitamin B12 deficiency, which leads to pernicious anemia

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion? Skin color Fluid intake Temperature Hemoglobin level

Temperature The greatest risk to the client is injury from a blood transfusion reaction. Therefore, the priority action is to take a baseline temperature measurement. The nurse should then monitor the client's temperature throughout the infusion as an increase in temperature can indicate an adverse reaction.

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. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia. For example, catheter changes, a distended bladder or bowel, enemas, and sudden position changes. Manifestations include elevated blood pressure, severe headache, and flushed face.

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction? The first 2 min The final 2 min The first 15 min The final 15 min

The first 15 min The nurse should remain in the room during the first 15 min of the infusion, which is the most critical time period for monitoring a client for a transfusion reaction. Severe reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.

A nurse is teaching a client who has a vitamin K deficiency about the effects of vitamin K. Which of the following information should the nurse include in the teaching? Vitamin K reverses warfarin toxicity. Vitamin K promotes fibrinogen formation. Vitamin K is produced in the gastric juices. Vitamin K is produced in the liver.

Vitamin K reverses warfarin toxicity. The nurse should understand vitamin K is an antidote to warfarin toxicity.

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider? Hct 45% WBC 1,700/mm3 Hgb 14.7 g/dL Platelets 160,000/mm3

WBC 1,700/mm3 A WBC count of 1,700/mm3 is a critical value that indicates the client is susceptible to infection. The nurse should report this value to the provider.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? pulse and blood pressure findings behavioral indicators and effect scheduled treatments and client illness a self-report pain rating scale

a self-report pain rating scale Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client's self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? "DIC is controllable with lifelong heparin usage." "DIC is characterized by an elevated platelet count." "DIC is caused by abnormal coagulation involving fibrinogen."

"DIC is caused by abnormal coagulation involving fibrinogen." DIC is caused by abnormal coagulation involving the formation of multiple small clots that consume clotting factors and fibrinogen faster than the body can produce them, increasing the risk for hemorrhage.

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? "Do have a history of chronic alcohol abuse?" "Have you had a recent influenza infection?" "Have traveled overseas recently?" "Are you taking a multivitamin?"

"Have you had a recent influenza infection?" The nurse should ask the client about a recent Haemophilus influenzae infection. The cause of GBS is unknown, but it usually follows a viral infection.

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching? "Take this medication with an antacid to reduce gastric irritation." "You may experience drowsiness while taking this medication." "You should take this medication with meals." "You may continue to breastfeed while taking this medication."

"You may experience drowsiness while taking this medication." The nurse should instruct the client that drowsiness can occur while taking this medication and to exercise caution while performing activities that require alertness.

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? "An MRI scan is not distorted by movement, so you do not have to lie still." "An MRI scan is a short procedure and should take no longer than 30 minutes." "The MRI contrast dye contains iodine and can cause your skin to itch." "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort.

A nurse is caring for an unconscious client who has a loss of the corneal reflex. Which of the following actions should the nurse take? Keep the room darkened. Apply lubricating eye drops. Alternate warm saline compresses to the eyes. Clean the eyes with a mild soap.

Apply lubricating eye drops. The nurse should apply lubricating drops to the eyes of a client who has a loss of corneal reflexes to prevent a corneal abrasion, due to the client's inability to blink.

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? When the client has finished eating lunch When the client states he is ready to start the infusion 2 hr after obtaining blood from the blood bank As soon as the nurse can prepare the client and the administration set

As soon as the nurse can prepare the client and the administration set The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? Eat plenty of fresh fruits and vegetables. Avoid crowds. Perform mild exercise, such as gardening. Take temperature weekly.

Avoid crowds. The nurse should inform the client to avoid crowds due to his suppressed immune system.

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program? Establish the ability to communicate effectively. Compensate for loss of depth perception. Learn to control impulsive behavior. Improve left-side motor function.

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include? History of smoking Obesity History of hypertension Genetics

Genetics Genetics is a nonmodifiable risk factor, which the client is unable to control.

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? Difficulty reading Inability to recognize his family members Right hemiparesis Aphasia

Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.

A nurse is completing a physical examination of a client and notes that laboratory values indicate leukocytosis. The nurse should recognize that which of the following manifestations is associated with leukocytosis? Anemia Coagulation disorders Inflammation Renal disorder

Inflammation Infection and inflammation are associated with leukocytosis, which is an elevated WBC count.

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.) Lubricate lips with water-soluble ointment. Brush teeth with a soft toothbrush. Blow nose gently. Limit fruit consumption. Use a straight edge razor to shave.

Lubricate lips with water-soluble ointment is correct. The nurse should instruct the client to lubricate his lips with water-soluble ointment to void cracking, which can result in spontaneous bleeding from the site Brush teeth with a soft toothbrush is correct. The nurse should instruct the client to brush his teeth with a soft toothbrush to avoid spontaneous bleeding of the gums. Blow nose gently is correct. The nurse should instruct the client to limit blowing the nose, and if needed, to blow the nose gently to minimize spontaneous bleeding from the nares.

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. Apply an eye patch to the client's right eye. Avoid the use of warm water to wash the client's face. Provide range-of-motion exercises to the client's neck and shoulders.

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 providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Provide client supervision. Limit client physical activity. Speak loudly to the client. Leave the television on continuously.

Provide client supervision. Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? Recombinant Packed RBCs Prophylactic antibiotics Fresh frozen plasma

Recombinant The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure before an invasive procedure, surgery, or when actively bleeding.

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 Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions? Spontaneous bleeding Oliguria Hyperactive deep tendon reflexes Infection

Spontaneous bleeding The nurse should consider the risk of spontaneous bleeding that can occur in clients who have low platelets. Low platelet levels cause clotting time to increase.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? Stop the infusion of blood. Inform the provider. Obtain a urine specimen. Notify the laboratory.

Stop the infusion of blood. This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? The laboratory values are within the expected reference range. The laboratory values are prolonged. The laboratory values are decreased. The laboratory values are the same as the previous test values.

The laboratory values are prolonged. These laboratory values measure clotting time. Because DIC results in the formation of multiple, small clots that consume key clotting factors, the nurse should expect the laboratory values to be prolonged.

A nurse is assessing a client's immune function by reviewing the laboratory value of the cellular response of the T-cells. The nurse should recognize that which of the following conditions is affected by the T-cells? Bacterial phagocytosis Hay fever allergy Transplant rejection Anaphylaxis

Transplant rejection Transplant rejection is affected by the cellular response, or cell-mediated immunity, of the T-cells.

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for side effects of immunosuppressants. constipation. fatigue. bleeding.

bleeding. MY ANSWER Thrombocytopenia refers to a decreased platelet count, which puts the client at risk for bleeding. In ITP, the immune system destroys healthy platelets, thinking they are foreign bodies. Using the airway, breathing, circulation (ABC) priority-setting framework is the priority concern for the nurse when providing care for this client.

A nurse is caring for a client who is going to have a bone marrow biopsy under conscious sedation. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nurse make? "The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." "Relax, you'll be asleep for most of the procedure and you won't remember a thing." "I will call your doctor and tell him you still have questions about the procedure." "I can understand because you must be very worried about what the biopsy will show."

"The biopsy can be uncomfortable, but I will try to keep you as comfortable as possible." The client is seeking information. This open-ended therapeutic response gives the client the information that the client needs to cope, reassures the client of the nurse's presence, and encourages further communication.

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A change in the Glasgow Coma Scale score from 13 to 11 Diplopia A drop in heart rate from 76 to 70/min Ataxia

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse at a blood donation center is screening clients for blood donation. The nurse should identify that which of the following clients must reschedule donation? A client who weighs 50 kg (110 lb) and plans to donate 450 mL of blood A client who is 14 years of age A client who is Rh-positive A client who has an oral temperature of 37.8° C (100° F)

A client who has an oral temperature of 37.8° C (100° F) A client who has an oral temperature that exceeds 37.5° C (99.6° F) defers eligibility to donate blood.

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply.) Decreased platelet count ​Increased hemoglobin count Decreased leukocyte count Increased platelet count Decreased erythrocyte count

Decreased platelet count is correct. The nurse should expect to see a decreased platelet count due to bone marrow suppression from the chemotherapy treatment Decreased leukocyte count is correct. The nurse should expect to see a decreased leukocyte count due to bone marrow suppression from the chemotherapy treatment. Decreased erythrocyte count is correct. The nurse should expect to see a decreased erythrocyte count due to bone marrow suppression from the chemotherapy treatment.

A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client? Close the door to the client's room. Pull the curtains around the client's bed. Ask family members to leave the room. Use sterile drapes to cover the client.

Pull the curtains around the client's bed. Pulling the curtains around the client's bed assures privacy for the client should someone open the door or enter the room.

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? Test the drainage for glucose. Suction the nostril. Notify the physician. Ask the client to blow his nose.

Test the drainage for glucose. This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data? The client can follow simple motor commands. The client is unable to make vocal sound. The client is unconscious. The client opens his eyes when spoken to.

The client opens his eyes when spoken to. A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain