Test 3 Foundations ATI
Which type of counseling is most effective for a situational crisis?
short term counseling
A client becomes very dejected and states, "No one really cares what happens to me. Life isnt worth living anymore." Which of the following responses should the nurse make?
"I care about you and am concerned that you feel so sad"
A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel and the nruse on next shift report the nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?
"I need to talk to you about unit expectations regarding delegating and completing tasks."
A nurse is reviewing information about HIPPA with a newliy licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? a. "information about a client can be disclosed to family members at any time." b."a clients address would be an example of personally identifiable information." c.HIPPA establised regulations of individually identifiable health information in verbal, electronic, or written form d. HIPPA is a federal law, not a state law
"information about a client can be disclosed to family members at any time."
What is the suffix for pain and suffering?
-algia
A nurse is caring for a client who is port op and is at rish for developing VTE. The nurse should instruct the client to acvoid which of the following unsafe actions?
massaging her legs
A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemo. The nurse should monitor for which of the following manifestations?
metabolic alkalosis
Which domain of complementary and alternative therapies uses a variety of techniques designed to enhance the mind's ability to affect bodily function and symptoms?
mind body medicine
A nurse asks a client to share personal stories. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship?
narrative interaction
A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography scan (CT). Prior to the scan, the client consumes 12 oz NA diatrizoate and meglumine diatrizoate. The client has an IV of D5W NS running at 75 ml/hr from 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500. At 1500, the client has 6 0z juice. How many mL should the nurse document as the clients intake for the shift?
375 ml 12 oz 6 oz 1200 ml
A nurse is caring for a client who is 4 days postop following a right radial mastectomy. Which of the following acitivites should the nurse anticipate being the most difficult for this client to perform with her right hand?
Combing her hair
A nurse sees an elderly patient walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. It is important that the nurse assess the patient for:
pain
A nurse is caring for a client who has DVT and is receiving IV fluid that contains 10,000 units of heparin in 500 mL infusing at 1,000 units/hr. When calculating the clients intake and output, how much should the nurse document as intake from this infusion in an 8hr shift?
400 mL
A nurse is caring for a client who is postoperative hip arthoplasty and has a new prescription for enoxaparin 1mg/kg dose subcutaneous every 12 hr. The client weighs 95 lbs. How many mg should the nurse administer per dose?
43.2 mg
A nurse is caring for a client who is postop following arthroplasty and has a new prescription for enoxaparin 1mg/kg dose subq every 12 hr. The client weighs 185 lb. How many mg should the nurse administer per dose?
84mg
A nurse is caring for an older client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. The doctor has ordered a CT and MRI of the brain. What are these tests?
Computerized Axial Tomography and Magnetic Resonance Imaging
A nurse in a provider's office is reviewing the lab findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
platelet count 60,000 mm3
During your initial assessment, you patient states thgat he eats a low fat diet. Your patient is participating in which of the following disease preventions?
primary prevention
A nurse is caring for a client who has CHF and is taking digoxin daily. The client refused breakfat and is complaining of N and wekaness. Which of the following actions should the nurse take first?
Check Vitals
A nurse is caring for a client who is 1 day post operative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?
Chvostek's SIgn The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
A nurse is caring for a patient who has crippling RA. Which nursing interventions best represents the use of integrative care?
the nurse administers naproxen and uses guided imagery to take the patients mind off the pain
Nursing is a form of help or assistance given by nurses to persons with a legitmate need for it.
true
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports weight loss of 12 lb in the last 2 months, increased appetite, increased perspirations, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?
provide a quiet, low stimulus environment.
A nurse is planning for a client who has end stage cirrhosis of the liver with encehalopathy. Which of the following interventions should the nurse plan to implement to decrease the clients ammonia level?
reduce the clients intake of protein.
IDentifing with the way that another person feels is considered ___
empathy
A nurse on a medical-srgical unit is caring for four clients who are 24 to 36 hours post op. Which of the following surgical procedures places the client at risk for DVT?
hip arthroplasty
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
increased HR increase BP increased RR
A rehabilitation nurse is caring for a client who has a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? a. Inform the client that privileges are related to participation in therapy b.Limit visiting hours until the client begins to participate in therapy c. Allow the client to control the timing and frequency of the therapy d. Establish a plan of care with the client that sets attainable goals
D
A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial developmetn?
intamcy vs isolation
A preferred method to establish ideal body weight include BMI and waist circumference. Which formula is best for calculating BMI using kg?
kg/m*m
Allopathic medicine has been dominant for about 100 yrs and has spearheaded remarkable advance in biotechnology. What area of care is Allopathic medicine most effective?
Emergency or acute situations
A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching?
Keep the open vial of insulin at room temperature
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse documents NKDA. What does this mean?
No known drug allergies
A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping becuase of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?
Obtain a pair of slipper sock for the client
A nurse is assessing a client prior to administration of morphine. The nurse should recognize that which of the following assessments is the priority?
RR
A nurse is caring for a client who is 8 hr post op following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?
Semi-Fowlers with neck in neutral postion
Handoff communication involves the process of accurate presentation and acceptance of patient-related info from one care giver or team to another caregiver or team using effective communication. As the ER nurse gives report to nurse HF on unit 3 W she states, I am concerned about her blood pressure because it has been ranged between 155-195/96-125. What aspect of hand-off communication is the ER nurse utilizing?
Situation
Anesthesia is a method and technique of making potentially uncomfotable interventions tolerable and safe. One form of anesthesia is regional. Select all the types of regional anesthesia listed below.
Spinal anesthesia Epidural anesthesia Nerve blocks
A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin with a cotton ball, and touches the patient skin with both sides of a safety pin. Which sense is the nurse assessing?
Tactile
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal commnication?
The clients sociocultural background influences nonverbal communication
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away; no one can help me." What should the nurse document?
Upon approaching the patient in the hall, the patient stated, "Go away, no one can help me."
A nurse is reviewing the lab results of a client who has fluid volume deficit. The nurse would expect which of the following findings?
Urine Specific Gravity 1.035
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?
Weak, Irregular pulse
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
acetone odor to breath
A nurse is caring for client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor?
bicarbonate excess circumoral paresthesia
A nurse notices that her 79 year old patient displays difficulty with spatial orientation, memory, and language. His wife state that she has noticed some changes in his personality in last few months. These symptoms are most likely related to which of the following.
dementia
In Orem's model, appropriate care for the patient is developed through a series of three operations. Select the three operations
dx regulatory prescriptive
Your patient is scheduled for a hernia repair. What classification of surgery is a hernia repair?
elective