MS1 ATI
a nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nose bleeds. the nurse should recognize that the client has which condition?
cirrhosis
a nurse is caring for a client with ITP. the priority concern is to monitor for:
bleeding
a nurse is caring for a client who has a prescription for a stool test for guaiac. the nurse understands the purpose of this test is to check the stool for which of the following substances?
blood
a nurse is caring for a client with dementia due to alzheimers and was admitted to a LTC due to the death of her partner of 40 years. the client states "I want to go home my husband is waiting for me to cook dinner" which of the following responses by the nurse is appropriate?
"tell me what you like to cook for dinner"
a nurse is teaching strategies to manage GERD. which statement should be included?
"avoid eating 2-3 hours before bedtime"
a nurse is giving DC instructions to a client with MS. the client reports symptoms of diplopia, dysmetria, and sensory change. what statement by the nurse is appropriate?
"implement a schedule to include periods of rest"
a nurse is caring for a client who has cirrhosis of the liver. which of the following assessment findings require follow up? SATA
BP 82/58 abd distension scattered ecchymosis on upper limbs high ammonia
a nurse is teaching a patient with CKD about the process of continuous ambulatory peritoneal dialysis. which of the following should the nurse include in teaching?
CAPD requires the client to follow fewer dietary and fluid restrictions compared to hemodialysis
a nurse is caring for a client who has GI bleeding. which of the following actions should the nurse take first?
assess ortho BP
a nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with crohns disease. which of the following information should the nurse include?
both are inflammatory
a nurse is assessing a client with parkinsons disease. which manifestations are expected?
bradykinesia
the nurse is teaching a client with a history of UC and a new dx of anemia. which manifestations of colitis should the nurse identify as a contributing factor to anemia?
chronic blood loss
a nurse is caring for a client with late stage alzheimers and is hospitalized for pneumonia. during night shift, the client is found climbing into the bed of another client who becomes upset and frightened. which of the following actions should the nurse take?
assist the client to the correct room
the nurse is caring for a client with a new AV graft in the left forearm. which of the following techniques should the nurse use to assess the patency of the graft?
auscultate for a bruit
a nurse is assessing a client in a health clinic for risk factors for contracting hepatitis. which client is at risk for developing Hep C?
a client who has multiple tattoos
a nurse is assessing four female clients for obesity. which of the following clients have manifestations of obesity?
a client who weights 28% over ideal body weight
a nurse at a health fair is assessing the weight status of four clients. which of the following clients are classified as overweight?
a male client who has a BMI of 29
a nurse is caring for a client who is cognitively impaired. which of the following rooms will provide a therapeutic environment to this client?
a room containing personal belongings
a nurse is caring for a client who has dementia. when performing a mental status exam MSE, the nurse should include which of the data? SATA
ability to perform calculations recall ability long term memory LOC
a nurse is planning a care for a client with liver cirrhosis. what should be included? SATA
administer furosemide measure abd girth implement low sodium diet
a nurse is caring for a client who has cushing's syndrome. the nurse should recognize that which of the following are manifestations of cushings? SATA
alopecia moon face purple striations buffalo hump
a nurse is preparing to administer a dose of lactulose to a client with cirrhosis. the client states "i dont need this medication. i am not constipated." the nurse should explain that in clients that have cirrhosis, lactulose is used to decrease levels of which of the following bloodstream components?
ammonia
a nurse is reviewing the lab data of a client with acute pancreatitis. the nurse should expect to find an elevation of which value?
amylase
the family of an older adult client brings him to the ED after finding him wandering outside. during assessment, the nurse notes flinching while palpating his abdomen yet responds to questions by nodding and smiling. which is the reason?
confusion
a nurse is assessing a client with CKD for fluid volume increase. which is a reliable measure of fluid volume?
daily weights
a nurse is reviewing the medical record of a patient who has been on levothyroxine for months. which of the following findings indicates a therapeutic response to the medication?
decreased TSH
a nurse is completing dietary teaching on consuming a low fiber diet with a client who has UC. which of the following foods should be eliminated in the client's diet?
dried apricots
a nurse is assessing a client who has myxedema. which of the following findings should the nurse expect?
facial edema
a nurse is assessing a client who has hyperthyroidism. the nurse should expect the client to report which of the following manifestations?
frequent mood changes
the nurse is planning care for a patient with diverticulitis. which of the following menu selections should the nurse include in the plan?
grilled chicken breast with white rice
a nurse is assessing a client a client who has thyrotoxicosis after taking too high of a level of levothyroxine. which of the following manifestations should the nurse expect?
heat intolerance
a nurse is reviewing the medical record of a patient who has a peptic ulcer. which of the following findings should the nurse recognize as a risk factor for this condition?
history of NSAID use
a nurse is assessing a client who has cushings syndrome. which findings should the nurse expect?
hyperpigmentation
a nurse is caring for a client with ESKD and reports having SOB and swelling in lower extremities. upon assessment, the nurse notes that the client has crackles in his lungs and elevated BP. The nurse should suspect which of the following?
hypervolemia
a nurse is assessing a client who is receiving liothyronine for hypothyroidism. the nurse should recognize which of the following findings is a therapeutic response to the medication?
increase in energy
a nurse is assessing a patient who is taking levothyroxine. the nurse should recognize that which is a manifestation of levo overdose?
insomnia
a nurse is providing teaching to a client with a new dx of hypothyroidism. on which of the following medications should the nurse prepare to instruct the client?
levothyroxine
a nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. the nurse should recognize confabulation when the client:
makes up stories when he is unable to remember actual events
a nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. which action should the nurse take?
move the client closer to the nurses station
a nurse is caring for a client who receives peritoneal dialysis. which manifestations of peritonitis should the nurse monitor for?
nausea and vomiting
a nurse is reviewing ABG results of a client suspected of metabolic acidosis. which of the results should the nurse expect to see?
pH below 7.35
a nurse is assessing a client who has advanced cirrhosis. which manifestation should the nurse expect?
petechiae
a nurse is caring for a client with dementia. the client is agitated and has difficulty staying in his chair. which of the following actions should the nurse take first?
place a seat alarm in the client's chair
a nurse is planning care for a client who has viral hepatitis. which of the following actions should the nurse include in the plan of care?
provide a high carb diet
a nurse is assessing a client admitted for hyperthyroidism. the client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, an increase in appetite, perspiration, fatigue, menstrual irregularity, and restlessness. which actions should nurse take to prevent thyroid crisis?
provide a quiet., low stimulus environment
a nurse is providing teaching to the family of a client with parkinsons. what should the nurse include?
provide client supervision
a nurse is caring for a client who is undergoing initial peritoneal dialysis. which of the following should the nurse report immediately to the provider?
purulent dialysate outflow
a nurse is planning care for a client with end stage cirrhosis of the liver with encephlophalopathy. which of the following interventions should the nurse implement to decrease ammonia levels?
reduce clients protein intake
a nurse is caring for a client who's ABG shows a pH of 7.3 and paCO2 of 50. what is this imbalance?
respiratory acidosis
a nurse is teaching self-management to a client with Hep B. which instructions should be included in teaching?
rest frequently throughout the day
a nurse is assessing a client with peritonitis. which findings are expected?
rigid abdomen
a nurse is caring for a client who needs a stool specimen collected. which of the following actions should the nurse take when obtaining the specimen?
send specimen container immediately to the lab
a nurse is caring for a client with Hep B. what should be encouraged?
short periods of ambulation
a nurse is caring for a client with ESRD. which of the following are expected findings? SATA
slurred speech bone pain pruritus
a nurse is assessing a client with cirrhosis. which is an expected finding for this client?
spider angiomas
a nurse is admitting a client with Hep C. which precautions should the nurse implement?
standard
a nurse is caring for a client with CKD receiving epoetin alfa. which lab result should the nurse consider a therapeutic med effect?
the hematocrit
a nurse is making a home visit to a client with alzheimers disease and the clients partner. which of the following observations indicates to the nurse that the partner is experiencing caregiver fatigue?
the partner has lost 20lb in the past 2 months
a nurse is caring for a client who receives intermittent enteral feedings through an NG tube. before administering a feeding, the nurse should measure gastric residual for what purpose?
to identify delayed gastric emptying
a nurse is teaching a client with CKD about limiting foods that are high in potassium. which foods should the nurse tell the client to avoid? SATA
tomatoes rasins
a nurse accidentally sticks her hand with a syringe needle after an IM injection. which action should she take first?
wash the area of the puncture thoroughly with soap and water
a nurse is preparing to obtain a daily weight from a client with CKD. which action should the nurse implement?
weigh after client has voided
a nurse is assessing a client who has hypothyroidism. the nurse should expect which of the following findings?
weight gain
