ATI Comprehensive Predictor Retake Review Solved 100%

Delegation to Assistive Personal - Answer - ADLs - Bathing - Grooming - Dressing - Tioleting - Ambulating - Feeding (without swallowing precautions) - Positioning - Rountine Tasks - Bed making - Specimen collection - I&O - Vital Signs ( for stable clients ) Planning Care for a Client Who Has Hypothyroidism - Answer - Monitor for low Bp & bradycardia - Monitor for chest pain & peripheral edema - Monitor clients weight - reorient the client if confusion occurs - provide frequent rest periods to avoid fatigue & decrease myocardial oxygen demands - Monitor respiratory status - encourage client to cough and breathe deeply to prevent pulmonary complications - low calorie, high fiber diet , & encourage fluids to prevent constipation and promote weight loss - Administer cathartics and stool softeners as needed. (Avoid fiber laxatives, interfere with absorption of levothyroxine) - Provide extra clothing and blankets for clients who have decreased cold intolerance - caution use of electric blankets - Encourage verbalization of feelings and fears about body changes - Reassure client that most physical manifestations are reversible - use caution with CNS depressants (barbiturates or sedatives) Signs of hypothyroidism - Answer - Fatigue/ lethargy - irritability - intolerance to cold - constipation - weight gain - pallor - think brittle fingernails - depression & apathy - joint or muscle pain - bradycardia, hypotension, dysrhythmias - slow thought process & speech - hypoventilation & pleural effusion - thickening of the skin - hair loss - thickening of hair on eyebrows - dry flaky skin - decreased acuity of taste - impotence - abnormal menstrual periods (menorrhagia/ amenorrhea) - delayed physical and mental growth in children Medication for hypothyroidism - Answer levothyroxin (synthetic thyroid hormone replacement) Risk factors for hypothyroidism - Answer - females 30 to 60 years of age - use of lithium & amiodarone medications - Inadequate intake of iodine - Radiation Therapy the head and neck What is hypothyroidism - Answer underactive thyroid Hyperthyroidism risk factors - Answer - Graves' disease - Thyroiditis - Toxic adenoma - Toxic nodular goiter - Exogenous hyperthyroidism What is hyperthyroidism? - Answer overactive thyroid Signs of hyperthyroidism - Answer - nervousness/ irritability - muscle weakness - heat intolerance - weight loss - insomnia - irregular menstrual flow - frequent stools and diarrhea - decreased libido - Tremor, hyperkinesia, hyperreflexia - Exophthalmos - blurry vision or changes - bloodshot appearance of eyes - Goiter - Tachycardia, palpitations, dysthymia - Elevated blood pressure - dyspnea Nursing care for hyperthyroidism - Answer - minimize clients energy - promote calm environment - monitor mental status - monitor nutritional status - monitor I&O / weight - provide eye protection (patches, eye lubricant, tape to close eyelids) - monitor vital signs and hemodynamic parameters - reduce room temp - provide cool shower/ sponge bath - Report a increased temp of 1*F immediately - Avoid excessive palpation of the thyroid Medication for hyperthyroidism - Answer - Methimazole Reinforcing Teaching About Ostomy Care - Answer stoma should be moist , shinny, and pink. The peristomal area should be intact - use mild soap and water to cleanse the skin, then dry it gently and completely ( moisturizing soaps interfere with adherence of the pouch) - Apply paste if necessary - measure and mark the desired size for the skin barrier - cut the opening 0.15 cm to 0.3 cm ( 1/18 to 1/8) in larger, allowing the stoma to appear through the opening - apply barrier paste to creases Developing a Improvement Plan for Assistive Personnel - Answer - performance should reflect the staff member's job and description - various sources of data should be collected - data should be collected over time and not just represent isolated incidents - actual observed behavior should be documented - peers can be a valuable source of data - the employee should be given the opportunity to provide input - the unit manager to host a private meeting with the staff member Monitoring the Performance of Assistive Personnel - Answer - have ap demonstrate the tasks before doing it Reinforcing Teaching About Client Privacy - Answer - only health care team members directly responsible for a clients care can access that client record. Nurses cannot share info with other clients or staff not caring for the client - Client have the right to read and obtain a copy of their medical record - Nurses cannot photocopy any part of a medical record - staff must keep medical records in a secure area. - staff cannot use public display boards toots clients names and diagnostics - Electronic records are at password protected - Nurses must not disclose clients info to unauthorized individuals or family members who request it by telephone or email unless person is able to give the code - communication regarding clients status should take place in private areas Obtaining Telephone Prescriptions - Answer - have a second nurse listen - repeat it back, making sure to include the medication's name ( spell it out) , dosage, time, and route - Question any prescription that seems inappropriate for the client - Make sure the provider signs the prescription in person within a 24hr time frame Evaluating Client Understanding of Nitroglycerin Storage - Answer - store tablets in original bottles - store in a cool dark place - store at room temperature - store away from light & moisture Prioritizing patient care - Answer - client with an acute problem takes priority over a client who has chronic problem - A client who has an urgent need takes priority over a client who has non urgent need - client who has unstable findings takes priority over a client who has stable findings Evaluating Understanding of Informed Consent - Answer - Consent is informed when a provider explains and the client understands: * the reason for the treatment or procedure * how the treatment or procedure will benefit the client * the risk involved with the procedure or treatment * other options to treat the problem, including not treating the problem Nurse role in Verifying informed consent - Answer - Witness clients signature on informed consent - ensure the provider gave the client the necessary info - notifying the provider if client has more questions *Nurse Documentation for informed consent*: - reinforcement of info originally given by the provider - questions the clients had were forwarded to the provider - use of an interpreter if needed Post op care after thyroidectomy - Answer - keep the client in a semi- Fowler's position - support head and neck with pillows & avoid neck extension - monitor vital signs every 15 mins then every 30mins - assist with deep breathing exercising every 30 to 60mins - ensure oral and tracheal suction is provided as needed - have tracheostomy supplies immediately available - humidify air and encourage cough - check the surgical dressing and back of the neck for excessive bleeding - check for laryngeal nerve damage by asking the client to speak as soon as awake from anesthesia and every 2 hrs after - administer pain meds and assure client discomfort will resolve after a couple of days - ensure that IV calcium gluconate or calcium chloride are immediately available Repositioning a client who is Immobile - Answer - use pillows, bath blankets, hand rolls, boots , splints, trochanter rolls, ankle support devices, and other aids to maintain proper body alignment - widen your base of support - face the direction of movement when moving the client. - if pushing, move your front foot forward and, if pulling, move your rear leg back to promote stability - avoid bending your back or twisting your spine - have another staff member help Decreasing Electrical Hazards - Answer - place electric cords against wall behind furniture - unplug equipment before cleaning it - grasp plugs at plug in when removing out the wall - avoid using extension cords Caring for a child who has Neutropenia - Answer - Monitor for signs of infection - use pharmacological and non-pharmacological around the clock interventions - avoiding public places, including schools - avoiding sick people - wearing a face mask if they must go out - washing hands well and often - brushing and flossing teeth every day - not using a rectal thermometer - cleaning cuts right after injury, then covering with a bandage - not using razors - avoiding certain foods, including: - unpasteurized dairy foods - raw fruits, vegetables, and nuts - do not give live vaccines - do not give fresh flowers Performing an Abdominal Exam - Answer - exam includes observing the shape of abdomen, palpating for masses, and auscultation for vascular masses - have client urinate before exam - have client lie supine with knees slightly bent - note any guarding or splinting of the abdomen - listen and inspect all 4 quadrants - inspect the umbilicus for position, shape, color, inflammation, discharge, and masses - palpate tender areas last - gurgles and tympany are expected sounds Reinforcing Teaching About Newborn Bathing - Answer - Bathing can began once newborn's temperature has stabilized to at least 36.5 *C (97.7*F) - a compete sponge bath should be postponed until thermoregulation occurs stabilizes - gloves should be worn until the newborn's first bath to avoid exposure to body secretions - avoid full bathing baby until cord falls off Reportable Findings for a 6 month old - Answer - average weight of a 6 month old is 16 pounds - head circumference increases 1cm(0.4 inches) per month - infant should be able to roll from back to front and hold their bottle - posterior fontanel closes 6-8 weeks - heart rate should be between 100-160 bpm - blood pressure should be: systolic 75-100 Diastolic 50-70 Postpartum Adjustments - Answer - allow verbalization of feelings - check emotional status - observe bonding with infant - Monitor for manifestations of postpartum blues or depression ( decreased appetite, difficulty sleeping, decreased interactions with others, lack of communication) Reinforcing Teaching About Caffeine Reduction - Answer - limit intake of tea, coffee, and soda - consume no more than 200 mg a day Appropriate Use of Contraception Spermicide - Answer - insert 15mins before sex - only effective 1hr after insertion, but should not be removed until 6 hr after intercourse - fold films prior to use and insert in the vagina where it dissolves - reapplied after each act of sex Appropriate Use of Contraception Diaphram - Answer - be properly fitted by a doctor - replace every 2 years and refit for 20% weight fluctuation, after abdominal or pelvic surgery, and after every pregnancy - prior to sex the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the Cervical side of the dome and around the rim - empty bladder prior to insertion to decrease pressure on urethra - washed with mild soap and warm water after each use Appropriate Use of Contraception Cervical Cap - Answer - insert up to 6 hr before sex and should be left in place for at least 6hr after sex, no more than 48 hr at a time - Replace every 2 years and refit after any gynecological surgery, birth, or any major weight fluctuation Appropriate Use of Contraception Contraceptive Sponge - Answer - one size fits all - moisten with water prior to insertion in the vagina - should be left in place for 6hr after the last act of intercourse and provides protection for up to 24hr Contraindications for Oral Contraceptives - Answer - Thromboembolic (DVT past or present) - stroke or heart attack - hypertension - coronary artery disease - gallbladder disease - cirrhosis or liver tumor - headache with focal neurological findings - diabetes mellitus - breast cancer - pregnancy - lactating - less than 6 weeks postpartum - smoker - over the age of 35 Preventing Dental Caries - Answer - established dental provider by 1 year of age - flossing and brushing should be done to remove plaque - brushing should occur after meals and at bedtime - nothing to eat or drink except water after teeth have been brushed - avoid putting kids to sleep with a bottle filled with juice or milk - consumption of cariogenic foods should be eliminated Clients at greatest risk for suicide - Answer - untreated depression - loss of employment/ finances - feelings of isolation/ powerlessness - prior attempts of suicide - change in functional ability - alcohol or substance use disorder - loss or loved ones - family history - Chronic illness or physical disorders - history of trauma /abuse - white race