RN ATI concept-based assessment, proctored exam for level 1 Test Bank. (Answered) With Rationales

40. A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the client's preferences into a sleep promotion plan? • Sleep in the location of your home where you feel you rest best • Rationale: The nurse should encourage the client to sleep wherever she feels she gets the most rest, whether it be a bed, couch, or chair. 41. A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. Which of the following statements should the nurse include in the teaching? • "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies." • Rationale: The nurse should teach the client how to select reliable internet websites when researching health care information. The nurse should identify that websites ending in ".gov" (government agencies) and ".edu" (educational organizations) are considered reliable and credible sources for health information. Websites ending in ".com" should not be used for researching credible health care information. 42. A nurse in an emergency room is caring for an infant who requires emergency surgery. The infant is accompanied by his 16-year-old mother and his maternal grandfather. Which of the following actions should the nurse take when assisting with informed consent? • Witness consent obtained from the infant’s mother • Rationale: The nurse should assist in obtaining informed consent from the infant's mother by witnessing her signature. Statutory guidelines indicate that a minor, even if unemancipated, can provide consent for her infant. Unemancipated minors can also legally provide informed consent for STI treatment, substance use treatment, and care related to pregnancy in some states. 43. A nurse is preparing to administer an immunization via IM injection into an adult client's deltoid muscle. Which of the following actions should the nurse take? • Select a 1-inch needle for the injection • Rationale: The nurse should select a 1-inch needle for an IM injection into the deltoid muscle. Depending on the client's weight, the nurse might need to use a 1 ½-inch needle to ensure injection of the vaccine into the muscle. 44. A nurse enters a client's room and finds the client lying on the floor. The client states that on the way to the bathroom her "knee locked," causing her to fall. Which of the following actions should the nurse take first? • Check the client for injuries • Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the client for injuries and measure vital signs to help determine physiologic stability. The nurse should also inform the provider of the client's fall and of the assessment findings. 45. A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to assess the quality of the client's pain? • Can you describe what your pain feels like? • The nurse should ask the client to describe her pain when assessing pain quality. The quality of a client's pain can be expressed using adjectives such as "piercing," "stabbing," and "aching." 46. A nurse is assessing a preschooler who has a urinary tract infection (UTI). Which of the following findings should the nurse expect? • Abdominal pain • The nurse should expect a preschooler who has a UTI to experience abdominal pain. Other manifestations include constipation, dysuria, foul-smelling urine, and fever.