ATI RN CONCEPT BASED ASSESSMENT LEVEL 3
Education for preventing child-hood obesity - ANSWER>>-avoid using foods as a reward
for good behavior
-have healthy foods like fruits and veggies available for snacking
-limit television watching to 2hr or less each day
-avoid offering juice drinks (high sugar content)
positive symptoms of schizophrenia - ANSWER>>Delusions of reference,
delusions of persecution, delusions of grandeur, thought broadcasting,
though insertion -magical thinking -auditory hallucinations -clang
association disorganized thought, disorganized behavior, catatonia
negative symptoms of schizophrenia - ANSWER>>-disturbance of affect
-blunting (severe reduction in the intensity of affect expression) -flat affect
-inappropriate affect (might laugh hysterically while describing someones death)
emotional ambivalence
nursing priority for patient with WILMs Tumor - >>-avoid palpation of
ANSWER abdomen
to avoid tumor rupture
What is Wilm's tumor? - ANSWER>>Renal tumor of embryonal origin that is most
commonly seen in children 2-5yrs
Assoc w/ Beckwith-Wiedemann syndrome (hemihypertrophy, macroglossia,
visceromegaly), NF, and WAGR syndrome (Wilms' Aniridia, Genitourinary abnormalities,
mental retardation)
Nursing intervention for child born at 33wks and is 2 days old - ANSWER>>-position
newborn SIDE-LYING or Prone while in nursery.
-bathe child in PLAIN WATER ONLY
-initiate skin-to-skin contact regardless of age or weight of newborn
-lights should be dimmed during the night and at intervals during the day
intimate partner violence >>nurses priority is to provide safety
teaching - ANSWER and
develop a safety plan.
Teaching for minimizing behavioral problems with client who has Alzheimer's disease
(AD) - >>-briefly leave the room when client becomes agitated
ANSWER
,-use a soft, calm tone of voice
-avoid crowds of people when taking client on outings.
manifestations of prenatal complications - ANSWER >>-swelling of finders, face, and
sacral area (these are hypertensive conditions like PREECLAMPSIA)
PYROSIS - ANSWER>>heartburn; burning sensation in upper abdomen due to reflux of
gastric acid
leukorrhea >>a profuse, whitish mucus discharge from the uterus and
- ANSWER vagina
Nursing actions for client with bipolar disorder experiencing mania - ANSWER>>-give
client short, firm direction when communicating -encourage frequent rest periods during
the day
-offer client high-fiber foods and extra fluids -supervise
client and give step-by-step directions.
risk factors for postpartum hemorrhage - >>usual suspects ANSWER plus:
-grand multiparitiy
multiple gestation, large infant, polyhydraminos dysfunctional
labor, oxytocin induction or augmentation
VBAC, general anesthesia
therapeutic response lab values for client with ANOREXIA NERVOSA - ANSWER
>>- BUN 18mg/dL (norm: 10-20 mg/dL)
-hematocrit 40% (norm: 42-52% males; 37-47% female)
-Na 138 mEq/dL (norm: 136-145 mEq/dL
-K 3.7 (norm: 3.5-5.0 mEq/dL)
Nursing action for client receiving IV OXYTOCIN and FHR shows VARIABLE
DECELERATIONS - ANSWER>>-administer O2 at 10 L/min via nonrebreather
reposition client to relieve compression to umbilical chord.
A nurse is caring for a client who has lung cancer and is exhibiting manifestations of
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following ndings
should the nurse report to the provider?
A. Behavioral changes
B. Client report of headache
C. Urine output 40 mL/hr
D. Client report of nausea
E. Increased urine specfic gravity - ANSWER>>A. Behavioral changes
B. Client report of headache
D. Client report of nausea
,A nurse is teaching a female adult client about screening prevention for cancer. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I will need to have a mammogram every 2 years beginning at age
45." B. "I should have a colonoscopy every 15 years beginning at age
60." C."I will need to have an annual breast examination every year after
40."
D."I should have a fecal occult test done every 3 years." - ANSWER>>C."I will need to
have an annual breast examination every year after 40."
A nurse is planning care for a client who has malnutrition due to cancer. Which of the
following interventions should the nurse include in the plan of care? (Select all that
apply.) A. Have the client keep a food diary.
B. Encourage tooth brushing before and after meals.
C. Assess laboratory test report of ferritin.
D. Monitor for changes in mental status.
E. Explain that fluid intake should occur between meals. - ANSWER>>A. Have the client
keep a food diary.
B. Encourage tooth brushing before and after meals.
C. Assess laboratory test report of ferritin.
E. Explain that fluid intake should occur between meals.
A nurse in an oncology clinic is reviewing the health record of a client who had surgery to
stage ovarian cancer. The nurse reviews the following diagnostic notation on the
pathology report: T2-N3-MX. Which of the following is an expected finding that supports
this diagnosis?
A. The tumor is 4 cm in size involving the ovary and adjacent tissues.
B. No lymph nodes contain cancer cells.
C. The tumor is receptive to current medication therapy.
D. The cancer has metastasized to other areas in the body - ANSWER>>A. The tumor is
4 cm in size involving the ovary and adjacent tissues.
A nurse in a clinic is caring for a client who has suspected uterine cancer. Which of the
following assessment techniques should the nurse anticipate the provider will perform on
this client?
A. Bimanual pelvic examination
B. Papanicolaou (Pap) test with cultures
C. Digital rectal examination
D. Percussion of the upper abdominal quadrants for tympany - ANSWER>>A. Bimanual
pelvic examination
A nurse is completing preprocedure teaching for a client who will undergo nuclear
imaging for suspected cancer. Which of the following is an appropriate statement by the
nurse?
A. "The presence of a liver enzyme will be identified."
B. "You will be given an injection of a radioactive substance."
C. "An endoscope will be inserted through your mouth."
, D. "The tumor will be aspirated." - ANSWER>>B. "You will be given an injection of a
radioactive substance."
A nurse is reviewing preoperative teaching with a client who will undergo a shave biopsy
for suspected cancer. Which of the following statements by the client indicates
understanding of the procedure?
A. "A test of my bone marrow will be performed."
B. "A lymph node will be removed."
C. "A needle will be inserted into the mass."
D. "A small skin sample will be obtained." - ANSWER>>A. INCORRECT: A bone marrow
aspiration is a type of needle biopsy.
B. INCORRECT: A sentinel node biopsy involves excision of a lymph node.
C. INCORRECT: A needle biopsy involves aspiration of a tumor for fluid and tissue
sampling.
D. CORRECT: A shave biopsy is a sampling of the outer skin layer using a scalpel or
razor blade.
NCLEX® Connection: Physiological Adaptations, Illness Management
A nurse is planning care for a client who will undergo genetic testing for suspected
cancer. Which of the following interventions should be included in the plan of care? A.
Obtain a signed informed consent form.
B. Withhold all medications prior to the procedure.
C. Verify the prescription for a tumor marker assay.
D. Ensure the client is placed in a recovery position after testing. - ANSWER>>A.
CORRECT: A signed informed consent form should be obtained prior to the procedure.
B. INCORRECT: Medication does not affect the results of genetic testing.
C. INCORRECT: A tumor marker assay is a laboratory test to identify the presence of
specific body proteins in blood, body secretions and tissue and is not a component of
genetic testing. D. INCORRECT: Genetic testing involves collection of blood or saliva
and a recovery positioning is not required following testing.
A nurse is planning care for a client who
has a platelet count of 10,000/mm3.
Which of the following interventions
should the nurse include in the plan of
care?
A. Apply prolonged pressure to puncture site after blood sampling.
B. Administer epoetin alfa as prescribed.
C. Place the client in a private room. D. Have the client use an oral topical anesthetic
before meals - ANSWER>>A. CORRECT: The nurse should implement bleeding
precautions for the client who has thrombocytopenia. B. Epoetin alfa is administered
to the client who has anemia.
C. The client who has neutropenia is placed in a private room.
D. A topical oral anesthetic is used for the client who has mucositis.
A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of
the following actions should the nurse take?
Education for preventing child-hood obesity - ANSWER>>-avoid using foods as a reward
for good behavior
-have healthy foods like fruits and veggies available for snacking
-limit television watching to 2hr or less each day
-avoid offering juice drinks (high sugar content)
positive symptoms of schizophrenia - ANSWER>>Delusions of reference,
delusions of persecution, delusions of grandeur, thought broadcasting,
though insertion -magical thinking -auditory hallucinations -clang
association disorganized thought, disorganized behavior, catatonia
negative symptoms of schizophrenia - ANSWER>>-disturbance of affect
-blunting (severe reduction in the intensity of affect expression) -flat affect
-inappropriate affect (might laugh hysterically while describing someones death)
emotional ambivalence
nursing priority for patient with WILMs Tumor - >>-avoid palpation of
ANSWER abdomen
to avoid tumor rupture
What is Wilm's tumor? - ANSWER>>Renal tumor of embryonal origin that is most
commonly seen in children 2-5yrs
Assoc w/ Beckwith-Wiedemann syndrome (hemihypertrophy, macroglossia,
visceromegaly), NF, and WAGR syndrome (Wilms' Aniridia, Genitourinary abnormalities,
mental retardation)
Nursing intervention for child born at 33wks and is 2 days old - ANSWER>>-position
newborn SIDE-LYING or Prone while in nursery.
-bathe child in PLAIN WATER ONLY
-initiate skin-to-skin contact regardless of age or weight of newborn
-lights should be dimmed during the night and at intervals during the day
intimate partner violence >>nurses priority is to provide safety
teaching - ANSWER and
develop a safety plan.
Teaching for minimizing behavioral problems with client who has Alzheimer's disease
(AD) - >>-briefly leave the room when client becomes agitated
ANSWER
,-use a soft, calm tone of voice
-avoid crowds of people when taking client on outings.
manifestations of prenatal complications - ANSWER >>-swelling of finders, face, and
sacral area (these are hypertensive conditions like PREECLAMPSIA)
PYROSIS - ANSWER>>heartburn; burning sensation in upper abdomen due to reflux of
gastric acid
leukorrhea >>a profuse, whitish mucus discharge from the uterus and
- ANSWER vagina
Nursing actions for client with bipolar disorder experiencing mania - ANSWER>>-give
client short, firm direction when communicating -encourage frequent rest periods during
the day
-offer client high-fiber foods and extra fluids -supervise
client and give step-by-step directions.
risk factors for postpartum hemorrhage - >>usual suspects ANSWER plus:
-grand multiparitiy
multiple gestation, large infant, polyhydraminos dysfunctional
labor, oxytocin induction or augmentation
VBAC, general anesthesia
therapeutic response lab values for client with ANOREXIA NERVOSA - ANSWER
>>- BUN 18mg/dL (norm: 10-20 mg/dL)
-hematocrit 40% (norm: 42-52% males; 37-47% female)
-Na 138 mEq/dL (norm: 136-145 mEq/dL
-K 3.7 (norm: 3.5-5.0 mEq/dL)
Nursing action for client receiving IV OXYTOCIN and FHR shows VARIABLE
DECELERATIONS - ANSWER>>-administer O2 at 10 L/min via nonrebreather
reposition client to relieve compression to umbilical chord.
A nurse is caring for a client who has lung cancer and is exhibiting manifestations of
syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following ndings
should the nurse report to the provider?
A. Behavioral changes
B. Client report of headache
C. Urine output 40 mL/hr
D. Client report of nausea
E. Increased urine specfic gravity - ANSWER>>A. Behavioral changes
B. Client report of headache
D. Client report of nausea
,A nurse is teaching a female adult client about screening prevention for cancer. Which of
the following statements by the client indicates an understanding of the teaching?
A. "I will need to have a mammogram every 2 years beginning at age
45." B. "I should have a colonoscopy every 15 years beginning at age
60." C."I will need to have an annual breast examination every year after
40."
D."I should have a fecal occult test done every 3 years." - ANSWER>>C."I will need to
have an annual breast examination every year after 40."
A nurse is planning care for a client who has malnutrition due to cancer. Which of the
following interventions should the nurse include in the plan of care? (Select all that
apply.) A. Have the client keep a food diary.
B. Encourage tooth brushing before and after meals.
C. Assess laboratory test report of ferritin.
D. Monitor for changes in mental status.
E. Explain that fluid intake should occur between meals. - ANSWER>>A. Have the client
keep a food diary.
B. Encourage tooth brushing before and after meals.
C. Assess laboratory test report of ferritin.
E. Explain that fluid intake should occur between meals.
A nurse in an oncology clinic is reviewing the health record of a client who had surgery to
stage ovarian cancer. The nurse reviews the following diagnostic notation on the
pathology report: T2-N3-MX. Which of the following is an expected finding that supports
this diagnosis?
A. The tumor is 4 cm in size involving the ovary and adjacent tissues.
B. No lymph nodes contain cancer cells.
C. The tumor is receptive to current medication therapy.
D. The cancer has metastasized to other areas in the body - ANSWER>>A. The tumor is
4 cm in size involving the ovary and adjacent tissues.
A nurse in a clinic is caring for a client who has suspected uterine cancer. Which of the
following assessment techniques should the nurse anticipate the provider will perform on
this client?
A. Bimanual pelvic examination
B. Papanicolaou (Pap) test with cultures
C. Digital rectal examination
D. Percussion of the upper abdominal quadrants for tympany - ANSWER>>A. Bimanual
pelvic examination
A nurse is completing preprocedure teaching for a client who will undergo nuclear
imaging for suspected cancer. Which of the following is an appropriate statement by the
nurse?
A. "The presence of a liver enzyme will be identified."
B. "You will be given an injection of a radioactive substance."
C. "An endoscope will be inserted through your mouth."
, D. "The tumor will be aspirated." - ANSWER>>B. "You will be given an injection of a
radioactive substance."
A nurse is reviewing preoperative teaching with a client who will undergo a shave biopsy
for suspected cancer. Which of the following statements by the client indicates
understanding of the procedure?
A. "A test of my bone marrow will be performed."
B. "A lymph node will be removed."
C. "A needle will be inserted into the mass."
D. "A small skin sample will be obtained." - ANSWER>>A. INCORRECT: A bone marrow
aspiration is a type of needle biopsy.
B. INCORRECT: A sentinel node biopsy involves excision of a lymph node.
C. INCORRECT: A needle biopsy involves aspiration of a tumor for fluid and tissue
sampling.
D. CORRECT: A shave biopsy is a sampling of the outer skin layer using a scalpel or
razor blade.
NCLEX® Connection: Physiological Adaptations, Illness Management
A nurse is planning care for a client who will undergo genetic testing for suspected
cancer. Which of the following interventions should be included in the plan of care? A.
Obtain a signed informed consent form.
B. Withhold all medications prior to the procedure.
C. Verify the prescription for a tumor marker assay.
D. Ensure the client is placed in a recovery position after testing. - ANSWER>>A.
CORRECT: A signed informed consent form should be obtained prior to the procedure.
B. INCORRECT: Medication does not affect the results of genetic testing.
C. INCORRECT: A tumor marker assay is a laboratory test to identify the presence of
specific body proteins in blood, body secretions and tissue and is not a component of
genetic testing. D. INCORRECT: Genetic testing involves collection of blood or saliva
and a recovery positioning is not required following testing.
A nurse is planning care for a client who
has a platelet count of 10,000/mm3.
Which of the following interventions
should the nurse include in the plan of
care?
A. Apply prolonged pressure to puncture site after blood sampling.
B. Administer epoetin alfa as prescribed.
C. Place the client in a private room. D. Have the client use an oral topical anesthetic
before meals - ANSWER>>A. CORRECT: The nurse should implement bleeding
precautions for the client who has thrombocytopenia. B. Epoetin alfa is administered
to the client who has anemia.
C. The client who has neutropenia is placed in a private room.
D. A topical oral anesthetic is used for the client who has mucositis.
A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of
the following actions should the nurse take?
