level 3 practice a.t.i
A nurse is caring for an older adult client who has kidney failure. The client tells the
nurse that she has decided to stop hemodialysis treatment. Which of the following
actions by the nurse is appropriate in regard to serving as the client's advocate? -
answer Supporting the client's decision regarding treatment
-The nurse's role as client advocate is to support the client's decision to discontinue
treatment.
A nurse is caring for an older adult client. The client received 0.9% sodium chloride 1 L
over 4 hr instead of over 8 hr as prescribed. Which of the following entries is the
appropriate documentation of this occurrence in the client's medical record? -
answer0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse
should document the amount of fluid, how long it took to infuse, and the client's physical
status.
When planning care for a child who has increased intracranial pressure (ICP), which of
the following should the nurse include in the child's plan of care? - answerMaintain head
in midline. -The child's head should be maintained in a midline position to promote
venous return and prevent an increase in ICP.
- answerSleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client
from sleep is an indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
A nurse is talking with a client who is beginning chemotherapy. She tells the nurse that
she is mourning the loss of her hair. Which of the following actions should the nurse
take first? - answerDiscuss the importance of hair with the client.--The first action the
nurse should take using the nursing process is to assess the client. By identifying the
importance of hair to the client, the nurse can acknowledge the importance of the
expected loss to the client and assist the client with anticipatory grieving.
- answeran inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math
skills, such as managing finances.
- answerFine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
, - answerDiscontinue the infusion.--A report of pain and a red line extending outward
from the insertion site are manifestations of phlebitis and indicates that the client is at
the greatest risk from injury to the vein; therefore, the first action the nurse should take
is to discontinue the infusion.
A client who is being discharged today asks the nurse for supplies for her wound
dressing. Which of the following actions should the nurse take to ensure quality, cost-
effective care? - answerProvide enough supplies for 1 to 2 days.-Although wound care
supplies for home use are typically purchased by clients after leaving the facility, it may
be necessary to provide adequate supplies for the immediate discharge period.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the
following should the nurse document as a therapeutic outcome? - answerDecrease in
flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for
improved muscle function.
A nurse is providing postoperative instructions about complete proteins to a client
following a below-the-knee amputation. Which of the following food choices indicates a
need for additional instruction? - answerPinto beans-
Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
A community health nurse is asked to give a health education program to a group of
African-American men age 40 to 75. Considering the health concerns of this group,
which of the following topics is most important to include in the program? -
answerProstate cancer screening-
The greatest risk for African-American males is death from prostate cancer. Therefore,
prostate cancer screening is the priority topic to include.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy
(ECT). The provider has explained the procedure to the client. Which of the following
statements made by the client indicates a need for further teaching? - answer"This
procedure can increase my risk for developing Parkinson's disease."-
Developing Parkinson's disease is not an adverse effect of ECT; therefore, this
statement indicates a need for further teaching.
A nurse is caring for a client who has an ileostomy and is 4 weeks postoperative. The
client reports leakage and irritation around the stoma. Which of the following is an
appropriate intervention? - answerInstruct the client to use a skin barrier when refitting
the pouch system.-
The client should use a skin barrier to protect the skin from enzymes and bile salts from
gastrointestinal drainage at the stoma site.
A nurse is caring for an older adult client who has kidney failure. The client tells the
nurse that she has decided to stop hemodialysis treatment. Which of the following
actions by the nurse is appropriate in regard to serving as the client's advocate? -
answer Supporting the client's decision regarding treatment
-The nurse's role as client advocate is to support the client's decision to discontinue
treatment.
A nurse is caring for an older adult client. The client received 0.9% sodium chloride 1 L
over 4 hr instead of over 8 hr as prescribed. Which of the following entries is the
appropriate documentation of this occurrence in the client's medical record? -
answer0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse
should document the amount of fluid, how long it took to infuse, and the client's physical
status.
When planning care for a child who has increased intracranial pressure (ICP), which of
the following should the nurse include in the child's plan of care? - answerMaintain head
in midline. -The child's head should be maintained in a midline position to promote
venous return and prevent an increase in ICP.
- answerSleepy/Widening pulse pressure//decerebrate posturing.....
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client
from sleep is an indication of increased ICP.//
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with
concurrent decrease in diastolic blood pressure) is an indication of increased ICP.//
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate
increased ICP.
A nurse is talking with a client who is beginning chemotherapy. She tells the nurse that
she is mourning the loss of her hair. Which of the following actions should the nurse
take first? - answerDiscuss the importance of hair with the client.--The first action the
nurse should take using the nursing process is to assess the client. By identifying the
importance of hair to the client, the nurse can acknowledge the importance of the
expected loss to the client and assist the client with anticipatory grieving.
- answeran inability to manage finances.--
Clients who are in stage 4 have difficulty with tasks that require planning and math
skills, such as managing finances.
- answerFine and gross motor skill challenges-
Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.
, - answerDiscontinue the infusion.--A report of pain and a red line extending outward
from the insertion site are manifestations of phlebitis and indicates that the client is at
the greatest risk from injury to the vein; therefore, the first action the nurse should take
is to discontinue the infusion.
A client who is being discharged today asks the nurse for supplies for her wound
dressing. Which of the following actions should the nurse take to ensure quality, cost-
effective care? - answerProvide enough supplies for 1 to 2 days.-Although wound care
supplies for home use are typically purchased by clients after leaving the facility, it may
be necessary to provide adequate supplies for the immediate discharge period.
A nurse is administering baclofen for a client who has a spinal cord injury. Which of the
following should the nurse document as a therapeutic outcome? - answerDecrease in
flexor and extensor spasticity-
Baclofen decreases the frequency and severity of muscle spasms, allowing for
improved muscle function.
A nurse is providing postoperative instructions about complete proteins to a client
following a below-the-knee amputation. Which of the following food choices indicates a
need for additional instruction? - answerPinto beans-
Pinto beans are a plant protein; therefore, this food choice is an incomplete protein.
A community health nurse is asked to give a health education program to a group of
African-American men age 40 to 75. Considering the health concerns of this group,
which of the following topics is most important to include in the program? -
answerProstate cancer screening-
The greatest risk for African-American males is death from prostate cancer. Therefore,
prostate cancer screening is the priority topic to include.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy
(ECT). The provider has explained the procedure to the client. Which of the following
statements made by the client indicates a need for further teaching? - answer"This
procedure can increase my risk for developing Parkinson's disease."-
Developing Parkinson's disease is not an adverse effect of ECT; therefore, this
statement indicates a need for further teaching.
A nurse is caring for a client who has an ileostomy and is 4 weeks postoperative. The
client reports leakage and irritation around the stoma. Which of the following is an
appropriate intervention? - answerInstruct the client to use a skin barrier when refitting
the pouch system.-
The client should use a skin barrier to protect the skin from enzymes and bile salts from
gastrointestinal drainage at the stoma site.
