ATI RN ASSESSMENT (1)

1. A nurse is planning medication teaching for a client who has ED. Which of the following medications should the nurse plan to include in the teaching? o Sildenafil 2. A nurse is caring for a client who has gestational hypertention and is experiencing PP hemorrhage. Which of the following medications should the nurse aniticipate administering? o Misoprostol 3. A nurse is assessing a 7-month-old infant who is experiencing developmental delays. Which of the following findings should the nurse expect? o Restricts attention to large objects 4. A nurse is caring for a client who is being seen for infertility and has a new prescription for clomiphene citrate. Which of the following manifestations should the nurse include in the teaching as a common adverse effect of the medication? o You might have breast tenderness while taking the medication 5. A nurse is discussing palliative care with the family of a client who is terminally ill. Which of the following information should the nurse include? o Palliative care includes a variety of therapies 6. A nurse is caring for a client who is experiencing hypovolemic shock due to postpartum hemorrhage. After notifying the provider, which of the following actions should the nurse take next? o Massage the clients fundus 7. A nurse in a provider’s office is performing a skin assessment on a client who reports concern about a lesion on her back. Which of the following images should the nurse identify as having the characteristics of melanoma? o The black one with irregular boarders 8. A nurse is assessing a client who is at 24 weeks of gestation. Which of the following findings should the nurse identify as an indication of gestational hypertension? o Diastolic BP of 98mmHg ▪ Gestational hypertension is anything over 140/90 9. A nurse in a mental health facility is caring for a client who has anorexia nervosa. Which of the following actions should the nurse take to help the client manage this eating disorder? o Limit the client’s intake of caffeine o Suggest high-fiber food choices o Use increments of 100 calories when advancing the client’s diestary intake 10. A school nurse is observing a preschooler who has autism spectrum disorder (ASD). Which of the following behavioral characteristics should the nurse expect the child to exhibit? o Ritualistic 11. A nurse is caring for a newborn who has a congenital heart deect and is postoperative following a cardiac catheterization. Which of the following actions should the nurse take? o Monitor the color of the affected extremity 12. A nurse is discussing family planning with a client who wants to use a diaphragm for contraception. Which of the following statement should the nurse include in the teaching? o You should be refitted for your diaphragm after a 20 percent weight fluctuation 13. A nurse is assessing a client who is at 34 weeks of gestation and is experiencing seere uterine pain. Which of the following findings should the nurse report to the provider? o Increased fundal height since admission 14. A nurse is providing teaching to a client who has epilepsy and is starting to take carbamazepine. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of this medication? o Blurred vision 15. A nurse in an acute care mental health unit is caring for a newly admitted client who has obsessive-compulsive disorder. The client is repeatedly washing her hands. Which of the following actions should the nurse take? o Teach the client to use thought-stopping techniques 16. A nurse is assessing a client who has acute pyelonephritis. The nurse should identify which of the following findings as an indication of inflammation? o Redness on the right flank 17. A nurse is assessing a 12-month-old infant who has Down Syndrome. Which of the following manifestations should the nurse expect? o Decreased muscle tone 18. A nurse is caring for a newly-admitted client who is at 37 weeks of gestation and is experiencing moderate placental abruption. Which of the following actions should the nurse take? o Insert a large-bore IV catheter 19. A nurse is caring for a client who has schizophrenia. Which of the following statements made by the client indicates delusions of reference? o Someone is trying to get a message to me through this newspaper 20. A nurse is assessing a client who has inflammatory bowel disease and is 1 day postoperative following a permanent ileostomy placement. Which of the following findings should the nurse report to the provider? o The stoma is retracted into the abdominal wall 21. A staff nurse tells the nurse manager that he consistently receives work assignments with a heavier work load than the other nurses on the shift. Which of the following actions should the nurse manager take to address the staff nurse’s report of bullying? o Check work assignments to validate the staff nurse’s claim. 22. A nurse is assessing a group of clients who have personality disorders. Which of the following clients should the nurse identify as having characteristics of schizoid personality disorder? o A client who dislikes having close relationships with other people 23. A nurse is providing teaching to the family member of a client who has delirium. Which of the following information should the nurse include? o Delirium can be brought on by the stress of an illness 24. A nurse is caring for a client who is receiving chemotherapy for non-Hodgkin’s lymphoma. Which of the following actions should the nurse take? o Instruct the client to wash drinking glasses after each use 25. A nurse is assessing a client who has rheumatoid arthritis (RA) and has been taking methotrexate for 4 months. Which statement by the client indicates to the nurse that the medication is effective? o “I have been able to go outside for walks lately” 26. A nurse is providing discharge teaching about home management strategies to a client who has multiple sclerosis (MS). Which of the following client statements indicates an understanding of the teaching? o I should schedule rest breaks between activities 27. A nurse is assessing a client who has acute glomerulonephritis. Which of the following findings should the nurse expect? o Rust-colored urine 28. A nurse in an emergency department is creating a plan of care for a client who reports a recent sexual assault. Which of the following interventions should the nurse plan to include? o Explain to the client the reason each procedure is conducted 29. A nurse is caring for a client who has diverticulitis. Which of the following medications should the nurse expect to administer? o Metronidazole 30. A nurse is teaching a client about family planning and the proper use of an intrauterine device. Which of the following client responses indicates an understanding of the teaching? o I will need to check that the two strings of this device are the same length once per month. 31. A nurse is reviewing the laboratory report of an adolescent client who has hemophilia A. Which of the following laboratory results should the nurse expect? o Coagulating factor VIII 50% 32. A nurse in an infertility clinic is providing a teaching to a client about her upcoming hysterosalpingography. Which of the following statements should the nurse make? o You might feel pain in your shoulder after the procedure 33. A nurse is caring for a client who has major depressive disorder. Which of the following client responses should the nurse identify as an overt statement indicating the potential for suicide? o I just can’t go on living like this any longer 34. A nurse in a providers office is caring for a client who is at 9 weeks of gestation ad is having her first prenatal exm. The client asks the nurse why she is being tested for sexually transmitted infections. Which of the following responses should the nurse make? o Most sexually transmitted infections are hard for you to detect. We screen all clients at their initial appointment. 35. A nurse is caring for a client who has a terminal illness and is approaching death. Which of the following actions should the nurse take? o Apply a thin coating of lip balm to the client’s lips 36. A nurse is providing teaching about combined oral contraceptives to a client who is 6 weeks postpartum. Which of the following instructions should the nurse include? o Some herbal supplements can alter the effectiveness of your oral contraceptives. 37. A nurse is caring for a client following a stroke. Which of the following actions should the nurse take? o Recommend a referral to the speech language pathologist 38. A nurse is caring for a client who was recently diagnosed with a terminal illness and is experiencing an intrapersonal crisis. Which of the following client statements indicates the use of rationalization? o I think this disease happened to me to test my belief system 39. A nurse is caring for a client who is pregnant and states that the first day of her last menstrual period was September 2 nd . Using Nagele’s rule, which of the following is the clients estimated date of deliver? o 0609 40. A nurse is teaching a client who has tobacco use disorder about the use of nicotine patches as an aid in smoking cessation. Which of the following statements indicates the client understands the teaching? o I should gradually decrease the dose of the nicotine patch over several weeks 41. A nurse is providing teaching to a client who has numerous severe food allergies on how to use an epinephrine auto-injector. Which of the following instructions should the nurse include? o Remove the activation cap from the injector o Insert the injector forcefully into the outer aspect of the thigh o Hold the device in place for 10 seconds o Massage the injection site for 10 seconds o Ensure the needle is projecting through the tip of the device 42. A nurse is teaching a client about obesity management. Which of the following information should the nurse include? o You should walk 5 days a week for 30 minutes 43. A nurse in a mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a cognitive symptom of schizophrenia? o Difficulty in decision making 44. A nurse in an acute care mental health facility is planning to care for a client who has major depressive disorder and who verbalizes feelings of hopelessness. Which of the following actions is the nurse’s priority? o Supervise the client closely during medication administration 45. A nurse is caring for a client who is in active labor and has a history of sexually transmitted infections. Upon Examination, the nurse notes a large, cauliflower-like cluster of lesions near the vagina. Which of the following actions should the nurse take? o Monitor the client for progressive fetal descent 46. A nurse is assessing a newly admitted client who has borderline personality disorder. Which of the following manifestations should the nurse expect? o The client exhibits a pattern of unstable interpersonal relationships 47. A nurse is teaching a client who has gestational hypertension about the condition. Which of the following statements made by the client indicates and understanding of the teaching? o I know my blood pressure should return to normal a few weeks after delivery 48. A nurse in a provider’s office is assessing a 2-month-old infant. Which of the following findings indicates the infant has a congenital heart defect? o Parent report respiratory destress while eating 49. A nurse is caring for a client who has HELLP syndrome. The nurse should monitor the client for which of the following manifestations o Stroke 50. A nurse in a pediatric unit is assessing a preschooler who has autism spectrum disorder. Which of the following findings should the nurse expect? o Spends long periods of time staring at spinning objects 51. A nurse in a provider’s office is preparing immunizations for a 12-month-old infant who is immunocompromised. Which of the following immunizations should the nurse plan to administer at this time? o HepB 52. A nurse is assessing a client who is at 28 weeks of gestation and is receiving magnesium sulfate for preterm labor. Which of the following findings is the priority for the nurse to report to the provider? o Decreased respiratory rate 53. An intensive care nurse is providing education about organ and tissue donation to the parent of an adolescent who has died following a motor-vehicle crash. Which of the following responses by the parent indicates an understanding of the teaching? o No one will notice the organs were donated if we have an open casket at the funeral. 54. A nurse is teaching a client who has genital herpes and a new prescription for acyclovir. Which of the following information should the nurse include regarding the expected outcome of the medication? o Acyclovir is given to promote healing of genital herpes 55. A nurse speaking with the family of a terminally ill client about organ donation. Which of the following statements by one of the client’s sons indicates and understanding of the organ donation process? o Our father will remain on life support until after the organs are removed 56. A nurse in an emergency department is speaking with the parent of a school-age child who has conduct disorder. Which of the following parent characteristics places the child at risk for maltreatment? o The parent makes most decisions on impulse. 57. A nurse is reviewing the lab report of a client who is at 34 weeks of gestation and has preeclampsia. Which of the following results should the nurse recognize as an indication that the client could be developing HELLP syndrome? o Alanine aminotransferase 41 units/L 58. A nurse is assessing a client who has epilepsy. The nurse should identify that which of the following client statements indicates the preictal phase of a seizure? o I suddenly smell a foul odor 59. A nurse is assessing a client for alcohol use disorder. Which of the following assessment scales should the nurse use? o Addiction Severity Index 60. A nurse on an acute care unit is caring for a newly admitted client who has bipolar disorder. Which of the following actions should the nurse take? o Prepare the client for hemodialysis 61. A nurse is assessing a client who has lung cancer. Which of the following manifestations should the nurse expect? o Persistent cough 62. A nurse is caring for a client who is experiencing preterm labor and is receiving betamethasone. Which of the following actions should the nurse take? o Monitor the client’s blood glucose level 63. A nurse is caring for a newborn who was born prematurely. Which of the following findings is the priority for the nurse to investigate further? o Grunting on expiration 64. A nurse is providing nurtritional teaching to a client who has leukemia and is experiencing neutropenia. Which of the following instructions should the nurse include? o Thaw frozen foods in the refrigerator o Avoid buffet-style restaurants 65. A nurse is creating a plan of care for a toddler who has cerebral palsy. Which of the following interventions should the nurse include? o Position the child upright for feedings 66. A nurse in an inpatient psychiatric facility is assessing a client who has schizoaffective disorder. Which of the following client statements indicates a flight of ideas? o My foot hurts. It’s time to eat lunch. I like movies. 67. A nurse is preparing to administer immunizations to a 2-month-old infant at a well-child visit. Which of the following immunizations should the nurse plan to administer? o Haemophilus influenzae type b 68. A nurse is assessing a client who is in the early stages of Alzheimer’s disease. Which of the following finding should the nurse expect? o The client misplaces familiar objects 69. A nurse is caring for a client who has preeclampsia and is receiving a 30-min bolus infusion of magnesium sulfate. The client appears flushed and states that she feels nauseated and extremely hot. Which of the following actions should the nurse take? o Reassure the client these are expected findings. 70. A nurse is providing discharge teaching to a client who is receiving radiation therapy for Hodgkin’s lymphoma. Which of the following client statements indicates an understanding of the teaching? o I will apply ice to the area if I get a bruise 71. A nurse is caring for a client who has eclampsia and has just experienced a tonic-clonic seizure. Which of the following actions should the nurse take? o Apply oxygen via nonrebreather at 10 L/min 72. A nurse is providing teaching about expected manifestations of the disease to the partner of a client who has Parkinson’s disease. Which of the following statements by the client’s partner indicates an understanding of the teaching? o She might have trouble swallowing, so I will offer her milkshakes to drink 73. A nurse is reviewing the laboratory report for a client who has acute pancreatitis. Which of the following laboratory results should the nurse expect? o WBC Count 21,000/mm3 74. A nurse is teaching an adolescent who has a severe allergy to bee stings about how to use an automatic-epinephrine injector. Which of the following statements by the client indicates an understanding of the teaching? o I will inject the medication into my upper thigh at a 90 degree angle 75. A nurse is providing palliative care to a client who is scheduled for surgery the following day. The client’s family is questioning the nurse about the necessity of the surgery. Which of the following responses should the nurse make? o Palliative surgery will relieve some of the pain your mother is experiencing 76. A nurse is providing family planning education for a client who wishes to conceive. The client brings her calendar to the appointment with her days of menses circled. The nurse should identify that ovulation is expected to occur on which of the following calendar dates? o D the 19th 77. A community health nurse is assessing an older adult client. Which of the following situations should the nurse identify as a possible indication of undue influence? o The client’s niece moves into her home to provide care 78. A nurse is caring for a client following a hemorrhagic stroke. Which of the following routine prescriptions should the nurse clarify? o Initiate alteplase infusion 79. A nurse is planning care for a client who has a benign chondroma of the tibia. Which of the following interventions should the nurse plan to include? o Palpate for changes in the muscle of the affected extremity 80. A charge nurse is leading an educational session about intimate partner violence for a group of newly-licensed nurses. Which of the following statements by a newly-licensed nurse indicates an understanding of the teaching? o Physical intimate partner violence is often passed on to future generations 81. A nurse is teaching a client who is experiencing preterm labor about receiving betamethasone. Which of the following outcomes should the nurse include in the teaching regarding betamethasone? o Enhances fetal lung maturity 82. A nurse in an acute care mental health facility is planning care for a client who has a bipolar disorder and who is experiencing acute mania. Which of the following actions should the nurse plan to take? o Provide the client with finger foods to eat 83. A nurse is caring for a client who is in active labor. The nurse notices an abnormal pattern on the fetal heart monitor. Which of the following actions should the nurse take for late decelerations? o Administer oxygen by nonrebreather facemask at 10 L/min 84. A nurse is providing teaching to a client who has parkinson’s disease and has a new prescription for levodopa-carbidopa. Which of the following instructions should the nurse include? o Change from a lying or sitting position slowly 85. A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following information should the nurse include? o Avoid large crowds of people when possible 86. A nurse is providing discharge teaching to a client following gastric bypass surgery for management of obesity. Which of the following client statements indicates an understanding of the teaching o I will remain in a reclining position for 30 minutes after I eat. 87. A nurse is caring for a client who has alcohol use disorder and recently completed detoxification. Which of the following medications should the nurse plan to administer to assist the client in maintaining abstinence from alcohol? o Disulfiram 88. A nurse is providing teaching to the parent of a school-age child who has sickle cell anemia. Which of the following statements should the nurse include? o You should report the provider if your child has a severe headache 89. A nurse is assessing a client who has post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect? o Memory loss related to the event 90. A nurse is assessing a young adult client for behaviors that indicate addiction. Which of the following characteristics should the nurse recognize as potentially indicating addictive behavior? o The client has a decreased self-image 91. A nurse manager is teaching a group of newly licensed nurses about obesity management for overweight clients. Which of the following information should the nurse manager include? o Decrease intake by 500 calories per day to lose 0.45kg (1lb) per week 92. A nurse is assessing a client who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? o Edema o Hematuria o Fatigue 93. A nurse in an emergency department is assessing a client who was in a motor-vehicle crash. The client has a blood alcohol concentration of 0.18% and states, “I would never drink and drive.” The nurse should identify that the client is demonstrating use of which of the following defense mechanisms? o Denial 94. A nurse manager is conducting an in-service about medications for substance use disorders with a group of staff nurses. Which of the following medications should the nurse manager include as an opioid agonist used in withdrawal therapy? o Methadone 95. A nurse is planning care for a client who has adenocarcinoma and associated thrombocytopenia. Which of the following actions should the nurse plan to take? o Initiate fall precautions for the client 96. A nurse is teaching a client who has genital herpes simplex virus. Which of the following statements should the nurse include in the teaching about this sexually transmitted infection? o You should cleanse the lesions with saline solution twice each day 97. A nurse is screening a female client for alcohol use disorder. Which of the following client statements should the nurse identify as a possible indicator of alcohol use disorder? o I know my partner wants me to drink less alcohol 98. A school nurse is evaluating a school-age child who has ADHD. Which of the following behavioral characteristics should the nurse expect the child to exhibit? o Intrusiveness 99. A nurse in a provider’s office is assessing a client who is 3 weeks postpartum. The nurse should recognize that which of the following manifestations is associated with postpartum depression? o Emotionless affect 100. A nurse is providing discharge teaching about newborn care to a client who is 2 days postpartum. Which of the following client responses indicates an understanding of the teaching? o It can take up to 3 weeks for my baby’s umbilical cord to fall off 101. A nurse in a provider’s office is caring for a client who is being evaluated for Alzheimer’s disease. Which of the following behaviors should the nurse identify as the earliest possible indication of Alzheimer’s disease? o The client is aware of his memory lapses 102. A nurse is developing a plan of care for a newly admitted client who has bulimia nervosa. Which of the following actions should the nurse plan to take? o Tell the client that privileges are based on treatment compliance 103. A nurse is assisting the provider in performing a mental status examination for neurocognitive disorder on a client who has dementia. Which of the following tasks should the nurse use to test the client’s constructional ability? o Ask the client to draw a clock that displays the time as 2:30 104. A nurse is assessing the fluid balance of a school-age child who has acute poststreptococcal glomerulonephritis and is experiencing inflammation. Which of the following actions is the nurse’s priority? o Maintain a strict record of the child’s daily weight 105. A nurse is assessing a 2-day-old newborn who was delivered at 32 weeks of gestation. Which of the following findings is the priority for the nurse to report to the provider? o Central Cyanosis 106. A nurse is assessing a client who has acute pancreatitis. Which of the following findings should the nurse expect? o Periumbilical discoloration 107. A nurse is caring for an infant who has tetralogy of Fallot. The nurse notes that the infant exhibits a sudden onset of cyanosis and is hyperpneic. Which of the following actions should the nurse take? o Place the infant in a knew-chest position 108. A nurse is creating a plan of care for a newborn who has a myelomeningocele. Which of the following interventions should the nurse include? o Place the newborn in a prone-kneeling position 109. A nurse is teaching a client about ways to prevent melanoma. Which of the following instructions should the nurse include in the teaching? o Keep a body map of skin abnormalities 110. A nurse is assessing an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following manifestations should the nurse expect? o Hematuria