Assessment Final 6: ATI Reviews for Abdomen and Neuro

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? A. The client needs total nursing care. B. The client is alert and oriented. C. The client is in a deep coma. D. Indicates stable neurologic status

A. (Rationale: A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care)

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear

A. (Rationale: Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear.)

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. B. Initiate a new IV line in the other extremity. C. Apply a hot pack to the irritated site. D. Determine if the client needs to continue IV therapy.

A. (Rationale: The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line)

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect? A. Vertigo B. Dysphagia C. Diplopia D. Apraxia

A. (Rationale: The nurse should expect a client who has an acoustic neuroma, a benign tumor of cranial nerve VIII, to manifest mild to moderate vertigo as time progresses. )

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? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension

A. (Rationale: The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).)

A nurse is caring for a client who has gastrointestinal bleeding. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. B. Explain the procedure for an upper gastrointestinal series. C. Administer pain medication. D. Test the client's emesis for blood.

A. (Rationale: Using the nursing process, the first action the nurse should take is to assess the client by measuring the client's orthostatic blood pressure. This action determines if the client is hypovolemic and establishes a baseline for further measurements.)

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing? A. Kidney beans B. Grilled salmon C. Peanut butter D. Raw spinach

B.

A nurse is assessing a client who is African-American and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice? A. Palms of the hands B. Hard palate C. Conjunctiva D. Back of the neck

B. (Rationale: According to evidence-based practice, inspecting the client's oral mucous membrane and hard palate are the most reliable methods to determine jaundice for a client who is African-American.)

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen

B. (Rationale: According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.)

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration? A. Institutional policies regarding routine medication administration times B. Specific characteristics of the medications C. Schedule of administration that the client follows at home D. Time at which the medication can be available from the pharmacy

B. (Rationale: Evidence-based practice indicates that the specific characteristics of the medications be the primary consideration of scheduling administration times. The characteristics of each medication, including the indication, onset, durations of action, and potential adverse effects and interactions, primarily determine the schedule of administration. Although an institutional policy may require that all once daily medications be administered at 0800, the nurse should be aware that some classifications of medications should only be given at bedtime, or should only be given with food. Likewise, the client's preferences, as well as the availability of each medication from the pharmacy, play important but smaller roles in determining the schedule of administration.)

A nurse is caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment questions should be the nurse's priority? A. "What do your bowel movements look like?" B. "How long have you been taking the bisacodyl?" C. "Do you take the bisacodyl with a glass of milk?" D. "How often do you have a bowel movement?"

B. (Rationale: The greatest risk to this client is injury from dependency on laxatives, as bowel tone can be lost; therefore, the priority question the nurse should ask the client is how long he has been using bisacodyl.)

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

B. (Rationale: 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 prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? A. Weigh the second client. B. Obtain vital signs for both clients. C. Administer pain medication to the first client. D. Change the dressings of both clients.

B. (Rationale: Using the nursing process as an organizing framework, the nurse should obtain vital signs on the two clients to determine if there are any emergent problems.)

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? A. Decreased WBC B. Increased serum amylase C. Decreased serum lipase D. Increased serum calcium

B. (Rationale: With acute pancreatitis, serum amylase rises within 24 hr of the start of the client's symptoms)

A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client? A. Moist skin B. Spider angiomas C. Tarry stools D. Blood in the urine

B. (Rationale:Spider angiomas are lesions with a red center and numerous extensions that spread out like a spider web. This is an expected finding for a client who has cirrhosis)

A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following groups of foods contains the highest level of carbohydrates? A. Milk, eggs, and cheese B. Butter, oils, and avocados C. Rice, potatoes, and oranges D. Chicken, green beans, and apples

C.

A nurse is teaching a client who needs to increase their daily fluid intake. Which of the following foods has the highest percentage of water by weight? A. Yogurt B. Milk C. Lettuce D. Honey

C.

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. Which of the following assessments is the nurse's priority? A. Pain B. Nausea C. Gag reflex D. Level of consciousness

C. (Gag reflex Rationale: The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed)

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture? A. Green-blue discharge in the ear canal B. Increased temperature C. Sudden pain relief D. Popping sensation when swallowing

C. (Rationale: Accumulation of exudate caused by otitis media with effusion increases pressure behind the tympanic membrane. The pressure releases when the tympanic membrane ruptures, which results in sudden pain relief)

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first? A. Auscultate B. Percuss C. Inspect D. Palpate

C. (Rationale: Evidence-based practice indicates the nurse should first inspect the abdomen for external abnormal conditions first.)

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? A. ½ cup ice cream B. 1 ounce swiss cheese C. 1 cup milk D. 1 cup cottage cheese

C. (Rationale: Of the four choices, milk contains the most calcium per serving. Milk contains 276 mg calcium per one cup serving.)

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. (Rationale: Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.)

A nurse is teaching a client who has a new prescription for esomeprazole to manage his GERD. Which of the following statements by the client indicates an understanding of the teaching? A. "I won't pass gas as often now that I am taking this medication." B. "I will take this medication each morning with my breakfast." C. "I have an increased risk of getting pneumonia while taking this medication." D. "I will need to take a daily stool softener while taking this medication."

C. (Rationale: The client taking esomeprazole is at a greater risk for developing pneumonia due to an elevation of gastric pH, especially during the first few days of treatment. The nurse should instruct the client about manifestations of a respiratory infection and to report these findings to the provider if they occur.)

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? A. Request a prescription for a medication to ease the client's anxiety. B. Irrigate the NG tube with 100 mL of sterile water. C. Check to see if the suction equipment is working. D. Remove and reinsert the NG tube.

C. (Rationale: The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.)

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Increased appetite C. Hyporeflexia D. Tachycardia

C. (Rationale: The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and hyperreflexia.)

A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy? A. 56-year-old who had a colonoscopy 6 years ago B. 34-year-old who reports a new onset of constipation C. 32-year-old who has a sister who died of colon cancer D. 51-year-old who is being seen for an annual physical examination

D. (Rationale: Colorectal cancer (CRC) is not common prior to the age of 40 years. When an adult turns 40, the provider should begin screening the client for risk factors of CRC (e.g., family history, inflammatory bowel disease, tobacco and alcohol use, high-fat and low-fiber diet, diet high in animal fats and red meat, sedentary lifestyle). The provider also may begin fecal occult blood testing depending on the client's risk. Screening colonoscopies are recommended starting at age 50 for those clients considered to be at normal risk with no family history and repeated every 10 years. It may begin earlier and performed more often for clients at high risk.)

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? A. Swollen gums B. Pruritus C. Urinary hesitancy D. Dysphagia

D. (Rationale: Dysphagia poses the greatest safety risk to the client because it can cause choking, or result in aspiration of food or liquids leading to pneumonia and respiratory compromise. This is the priority finding for the nurse to address.)

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report A. loss of central vision. B. having a loss of peripheral vision. C. seeing bright flashes of light and floaters. D. having a decreased ability to perceive colors.

D. (Rationale: Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors.)

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first? A. Disconnect the tube from the wall suction. B. Perform hand hygiene. C. Provide mouth care to the client. D. Verify the provider's prescription to discontinue the tube.

D. (Rationale: The first action the nurse should take using the nursing process is to assess the provider's prescription to confirm the NG tube should be removed. Discontinuing an NG tube requires a provider's prescription. Therefore, confirmation of the prescription is a priority before removal of the tube. Nasogastric tubes are used to provide enteral nutrition, to administer medication, and to provide gastric decompression. If the NG tube is still required by the client, removing it can cause injury to the client.)

A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? A. One cup of brown rice B. One cup of orange juice C. One cup of pureed avocado D. One cup of lentils

D. (Rationale: The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.)

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? A. Loss of consciousness lasting 30 to 60 min B. Glasgow Coma Scale score of 11 C. Nuchal rigidity D. Sensitivity to light

D. (Rationale: The nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise.)

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority? A. Epigastric discomfort B. Dyspepsia C. Constipation D. Hematemesis

D. (Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is hematemesis, which indicates massive bleeding.)