ATI RN FUNDAMENTALS PTOCTORED EXAM Q&A

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of non adherence -incorrect: It is important for the client to understand all aspects of the illness as well as the consequences of non adherence to recommend lifestyle changes. However, when the nurse is trying to motivate the client to make lifestyle changes, the client might perceive warnings about the dangers of non adherence as a threat. Instead, the nurse should present this information after the client commits to making the recommended changes. B. Schedule learning sessions to demonstrate the psychomotor skills the client will need -incorrect: Scheduling meetings about psychomotor skills is important for showing the client how to practice self-care. However, this is unlikely to encourage the client to make an initial commitment. This strategy will likely strengthen the client’s adherence to the recommended life changes after the client has made an initial commitment to them. C. Provide clearly written and easy-to-understand materials -incorrect: It is important for the client to understand all aspects of the illness, and clearly written and easy-to-understand instructional materials can be helpful. However, the nurse should present this information after the client is committed to change. D. Help the client identify ways that these changes will result in positive personal outcomes -According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that’s the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A. Holding a community clinic to administer influenza immunizations -incorrect: Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill. B. Screening groups of older adults in nursing care facilities for early influenza manifestations -Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent an illness from becoming severe. C. Educating parents of young children about the dangers of influenza -incorrect: Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill. D. Finding rehabilitation programs for older adults who have complications related to influenza -incorrect: This is an example of tertiary prevention, which seeks to prevent complications and help people recover from an existing illness. A nurse is obtaining the blood pressure in a client’s lower extremity. Which of the following actions should the nurse take? A. Auscultate the blood pressure at the dorsalis pedis artery -incorrect: The nurse should auscultate the blood pressure at the popliteal artery. B. Measure the blood pressure with the client sitting on the side of the bed -incorrect: The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed. C. Place the cuff 7.6 cm (3in) above the popliteal artery -incorrect: The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery. D. Place the bladder of the cuff over the posterior aspect of the thigh -This is the correct position for the bladder of the cuff when the nurse is measuring a lower extremity blood pressure. A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? A. “When did you start to believe in your faith?” -incorrect: This is a nontherapeutic response that assumes the client has a religion-based belief system. Spirituality can include religious beliefs but does not depend on their existence. B. “How often do you perform religious rituals?” -incorrect: This is a nontherapeutic response that assumes the client has a religion-based belief system. Spirituality can include religious beliefs but does not depend on their existence. C. “Which church do you regularly attend?” -incorrect: This is a nontherapeutic response that assumes the client has a religion-based belief system. Spirituality encompasses many aspects of the client’s ideas about life and can include religious beliefs but does not depend on their existence. D. “What is your source of strength and hope?” -This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse’s part. It correctly focuses on a global view of spirituality as a complex concept that encompasses the client’s life experiences and beliefs about strength, love, and hope. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. Loss -At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety. B. Trust -incorrect: The nurse should address the concept of trust during the introductory phase of the relationship. C. Self-disclosure -incorrect: The nurse should address the concept of appropriate self-disclosure during the working phase of the relationship D. Risk-taking -incorrect: The nurse should address the concept of risk-taking in the working phase of the relationship. A nurse is assessing a client’s nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10lb)? A. 10 months B. 5 months -incorrect: At the rate of 1 lb per week, the client would gain 20-25 lb in 5 months. C. 5 weeks -incorrect: At the rate of 1 lb per week, the client would gain 5 lbs in 5 weeks D. 10 weeks - Because 1 lb of body fat is equivalent to 3,500 calories, consuming 500 extra calories each day for 7 days would lead to a total of 3,500 calories and a 1 lb gain per week. At the rate of 1 lb per week, the client would gain 10 lb in 10 weeks. A community health nurse is teaching a group of clients about kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include?  Contact your pelvic muscle when performing the exercises  Expect improvement after 2 weeks of performing the exercises  Hold your breath when performing the exercises  Tighten your buttocks when performing the exercises A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?  Skin tags noted in the neck region  A change in appearance of a mole on the shoulder  A flat, nonpalpable, discovered area of skin on the trunk  Atrophic wart on the left index finger A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take? A cover the client with heavy blankets after shivering