ATI RN Concept-Based Assessment Level 3 Study Guide Rated A+ 2025

orthostatic hypotension - caused by DEHYDRATION from fluid loos and electrolyte imbalance gross motor skills - physical abilities involving large body movements, such as walking and jumping -EX: 9 month-old infant SHOULD be able to sit UNSUPPORTED for up to 10 MIN Biofeedback - technique that uses audio and visual signals that allow client to reduce muscle tension by gaining control over autonomic physiologic functions. How should phenytoin be administered? Why? - -administered IV bolus at a rate no greater than 50mg/min. -to prevent HYPOTENSION and BRADYCARDIA Manifestations of Parkinson's Disease - tremor, rigidity, BRADYKINESIA, postural instability, depression and other psychiatric changes, dementia, autonomic symptoms, sleep disturbances Non-Hodgkin's Lymphoma - spreads ERRATICALLY through the LYMPHATIC SYSTEM to other organs. It also manifest in PAINLESS, swollen lymph nodes found in the CERVICAL, AXILLLARY, INGUINAL, & FEMORAL areas. Hodgkin's lymphoma - spreads SYSTEMICALLY from one group of lymph nodes to the next group of nodes. Important teachings for client with new prescription of a DIAPHRAGM. - -should remain in place for 6HR FOLLOWING INTERCOURSE -should remove diaphragm NO MORE THAN 24HRS following intercourse -insert diaphragm NO MORE THAN 6HR PRIOR to intercourse -apply about 10ml (2tsp) of SPERMICIDE inside diaphragm prior to intercourse -replace every 2 yrs. -client should be refitted if their weight FLUCTUATE BY 20% -client should be refitted following a ABDOMINAL SURGERY, PELVIC SURGERY, & after each pregnancy A client with fibrocystic breast condition will... - have BREAST PAIN and tenderness as well ass LUMPS usually in the UPPER OUTER QUADRANT of the breast. Expected findings of INTRADUCTAL PAPILLOMA BREAST disorder? - finding will include: -mass in duct and NIPPLE DISCHARGE ATI RN Concept-Based Assessment Level 3 Study Guide Rated A+ 2025 Expected findings of DUCTAL EXTASIS BREAST DISORDER? - Enlarged axillary nodes and Nipple discharge. Client with COPD will experience... - DIGITAL CLUBBING, which DECREASES arterial O2 levels. tophi with chronic gout - hard, painless nodule on first toe, collection of NA urate crystals due to chronic gout, sometimes bursts with chalky discharge Swan neck deformity - -hyperextension of PIP joint and flexion of DIP joint -late manifestation of RHEUMATOID ARTHRITIS (RA) scleroderma - chronic progressive disease of the skin and internal organs with hardening and shrinking of connective tissue -EXPECT flexion or contracture of joints. (late manifestation) Preferred meal plan for a patient with DIVERTICULITIS - -advance to high-fiber diet. Best source of fiber is a BANANA which yields 3.1g of FIBER. Diverticulitis - inflammation of the diverticula What type of medication can increase a patient's risk for a stroke? - -oral contraceptives B/C this will INCREASE the risk for developing a THROMBOEMBOLISM. A client with HYPOPITUITARISM places the them at risk for developing what type of condition? - -osteoporosis How does light to moderate drinking, (150ml or 5oz of wine each day) affect the client's risk for having a stroke? - it doesn't increase, it actually DECREASES the risk for stroke. What is Ewing Sarcoma? What are expected manifestations of this disease? - -rare malignant tumor arising in bone; most often occurring in children -client will experience pain in the UPPER THIGH as well as LOCALIZED PAIN, SWELLING, & PALPABLE MASS. What are expected findings of Multiple Sclerosis (MS)? - -decrease visual acuity, diplopia, changes in peripheral vision, & nystagmus (repeat of uncontrolled movements). What are expected finding of Amyotrophic Later Sclerosis (ALS)? - -fascifulcations of the face, twitching of the face or tongue. What is Amyotrophic Lateral Sclerosis (ALS)? - Also known an Lou Gherig's disease, ALS is a motor neuron disease which can lead to paralysis. borderline personality disorder - condition marked by extreme instability in mood, identity, and impulse control. -client's with this condition experience SUICIDAL IDEATION & SUBSTANCE ABUSE. narcissistic personality disorder - characterized by a grandiose sense of self- importance, a preoccupation with fantasies of success or power, and a need for constant attention or admiration or ARROGANCE historonic personality disorder - Impulsive attention seeking behavaior paranoid personality disorder - A personality disorder characterized by a pervasive distrust and suspiciousness of the motives of others without sufficient basis What are some complications of an infant born at or less than 32 weeks? - -apnea -nectrotizing enterocolitis (due to intestinal ischemia and immature immune system) -hypoglycemia -anemia -polycythemia -hypothermia What teachings should the nurse include for a client that underwent a UTERINE ARTERY EMBOLIZATION? - -client may experience flu-like symptoms for 7 days after procedure (embolectomy syndrome) -inform client that a CLOSURE DEVICE or INJECTION that blocks blood flow to the arteries of the FIBROID TUMOR is used -inform client that SEVERE CRAMPING may occur in the first 24hr after the procedure and can last up to 2 weeks. What teachings should the nurse include for a client who has bipolar disorder and has a new prescription of LITHIUM? - -instruct client to take Li with meals to decrease irritation of gastric mucosa. -maintain adequate intake of salt (low Na can lead to Li retention, which can cause Li toxicity). -drink at least 1.5-3L of fluids each day (dehydration can lead to Li toxicity). -expect WEIGHT GAIN (common adverse effect of Li). Autism Spectrum Disorder (ASD) - A disorder characterized by deficits in social relatedness and communication skills that are often accompanied by repetitive, ritualistic behavior. Immunization schedule - Birth: Hep B 2 mos: Hep B, ROTAVIUS, DTaP, Hib, Pneumococcal, Poliovirus 4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus 6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus 12 mos: MMR, VAR, Hep A, Influenza, Hib 11-12 YEARS: Tdap, Meningococcal, HPV ADHD (Attention-Deficit Hyperactivity Disorder) - a psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity What should the nurse include in her planning for a patient who has ACUTE phase of DIVERTICULITIS? - -Instruct the client to AVOID COUGHING (this can increase the intra-abdominal pressure and cause BOWEL PERFORATION). -ADMINISTER OPIOID analgesics to relieve pain (this can decrease bowel motility) -DO NOT administer EMEMAS or LAXITIVES (this will increase bowel motility and places client at risk for bowel perforation) -client should be NPO or on a clear liquid diet (this will decrease inflammation of the bowels). sickle cell crisis - condition in sickle cell anemia in which the sickled cells interfere with oxygen transport, obstruct capillary blood flow, and cause fever and severe pain in the joints and abdomen. How should the nurse manage care for a client who is experiencing a sickle cell crisis? - -promote fluid intake to prevent dehydration -monitor peripheral capillary refill, pulse O2, and skin temp every 1hr to assess PERFUSION of EXTREMITIES. -EXTEND client's knees to promote perfusion of lower extremities. -elevate head or bed to 30 DEGREES or less to increase perfusion to lower extremities. What are the depressive manifestation of low self-esteem? - -hypersensitivity to criticism -guilt -shame -expression of helplessness -lack of eye contact -pessimistic outcome on life What are the manifestations of spiritual distress? - -express lack of meaning in life -anger -refusing interactions with family -discontinuing spiritual practice What are the manifestations of disturbed thought process? - -impaired problem-solving skills -confusion -difficulty concentration -inappropriate thinking -memory deficits What are the nursing interactions for palliative care of near death clients? - -administer analgesics like morphine SUB Q, SUBLINGUAL, or IV if the client is NOT RESPONSIVE. -APPLY A SOCOPALAMINE TRANSDERMAL PATCH or administer ATROPINE to decrease oral or respiratory secretions. -provide soothing music, use therapeutic touch, and keep noise level low -don place heating pads on extremities What teachings should the nurse include to a client who is preclamtic WITHOUT severe features? - -inform client to use SIDE-LYING POSITION when resting in bed or on couch -monitor blood pressure 2 times a week What teachings should the nurse include to a client who is preclamtic WITH severe features? - -limit fluid intake to PREVENT PULMONARY EDEMA -maintain a DARK, QUIET ENVIRONMENT to avoid stimuli that can cause seizure activity. How should the nurse plan her care to a client with anorexia nervosa? - -observe client for 60 MIN AFTER MEALS -weigh client each day early in the morning after voiding, while wearing the same amount of clothing each day. -EMPHASIZE SOCIAL ASPECTS of eating during mealtimes. What drug may cause an adverse affect when combined with METAMINE? - -SODIUM BICARBONATE (antacid used to treat GI upset) b/c this can increase accumulation of METAMINE which can lead to TOXICITY Teachings for client who has genital herpes - -wear gloves when applying anesthetic ointment -begin ORAL ANTIVIRALS with in 1 day of outbreak -use latex or plyurethane condoms during sexual intercourse. -take a sitz bath 3-4 times a day to help minimize discomfort What meds should the nurse expect to administer for a client who is in post-partum and experiencing hemorrhaging? - -METHYLERGONOUINE (causes contractions of the uterine muscle, which decreases bleeding. Adverse affect is HTN). -MISOPROSTOL (uterotonic med) What meds should the nurse expect to administer for a client who is in PRE-TERM LABOR? - -BETHAMETHASONE (glucocorticoid given to stimulate fetal lung maturity) -TERBUTALINE (tocolytic med which causes relaxation of smooth muscles of the uterine wall). What meds should the nurse expect to administer for a client who is experiencing PRE- ECLAMPSIA? - -MAGNESIUM SULFATE (prevents seizures) -NIFEDIPINE (Ca Channel blocker that relaxes vascular smooth muscles which lower BP). How should a nurse plan care for a client with DEMENTIA? - -USE LARGE CALENDARS that are easy for client to read. -keep client's room dimly lit at night to prevent falls and wandering -speak slowly to client in a NORMAL VOLUME -provide SIMPLE explanation and directions What are some signs/symptoms of OPIOID WITHDRAWAL? - -RHINORRHEA -yawning -tearing -hyperthermia -TACHYPNEA -diaphoresis -enlarged pupils -hyperflexia What are the early manifestations of ALS? - -fascilfulcations of the face -twitching of the tongue -nasal tone of voice leading to DYSARTHRIA (diff speaking) -muscle atrophy of ARMS & HANDS Client teaching for gestation HTN - -gestations HTN will resolve during the 1st week of postpartum but can last for 12 wks. -gestational HTN will begin around 20th week of pregnancy -client will NOT EXPERIENCE vaginal discharge for a few days. What are some contraindications for a client taking ORAL CONTRACEPTIVES? - - patient that is EXPERIENCING a HEADACHE w/aura -client who has a history of DM for 20 yrs w/ vascular disease -client who has liver tumors, HTN, and/or GALL BLADDER disease What are the nursing interventions for a newborn with PDA? - -offer small frequent feedings. -weight infants DAILY at the same time of day using the same scale. -ASSESS APICAL pulse ever 2-4 hours. -elevate infants bed to 30-45 degrees. What should the nurse tell a patient who has experienced sexual violence? - "You are safe here." What are the expected lab values for a client with HELLP SYNDROME? - -WBC <100,000 mm3 -HCT < 33% -SERUM URIC ACID <2.7 OR >7.3 mg/dL (due to decreased renal perfusion) -BUN <10 or >20 mg/dL What are some of the manifestations of DOWN'S SYNDROME? - -DEPRESSED NASAL BRIDGE -small nose -belpharitis (up and outward slant of the eyes) -board, short hands w/stubby fingers -protruding abdomen How should the nurse plan her car to a patient with a gambling disorder? - - ADMINISTER Li, carbamazepine, NALTREXONE, & SSRIs -RECCOMMEND joining a self-help group. aversion therapy - form of behavioral therapy in which an undesirable behavior is paired with an aversive stimulus to reduce the frequency of the behavior Ex: used to treat client who have SEXUAL PARAPHILIAS Disulfiram (Antabuse) - -Used for alcohol aversion therapy. -Clients started on Disulfiram must avoid any form of alcohol or they would develop a severe reaction. -Teach pt to avoid some over-the-counter cough preparations, mouthwash etc. major depressive disorder - -A mood disorder in which a person experiences, in the absence of drugs or a medical condition, two or more weeks of significantly depressed moods, feelings of worthlessness, and diminished interest or pleasure in most activities. -Ex: a client who had a RECENT MOVE ACROSS the country to look for work How to calculate caloric intake for an obese client that is wanting to lose 2lbs of body fat per week and is currently consuming 2500 calories per day? - -know that 1lb of body fat = 3500 calories -multiply 3500 by 2= 7000 (amount of calories client needs to lose per week) -divide 7000 (calories) by 7 (days)= 1000 (calories needed to be subtracted from the current daily caloric intake). -subtract 1000 from 2500= -1500 (calories needed to be consumed DAILY to meet weekly weight loss. Manifestations of major depressive disorder - -Insomnia -Feelings of worthlessness or excessive guilt -Fatigue or loss of energy -Diminished ability to concentrate -Substantial change in appetite or weight -Psychomotor agitation/retardation -Recurrent thoughts of death or suicide bipolar disorder - severe mood swings between major depressive episodes and manic episodes -client may exhibit MANIPULATIVE behavior Nursing Process - Assessment Diagnosis Planning Implementation Evaluation What are the nursing interventions/teaching for a client who has ACUTE GLOMERULONEPHRITIS? - -restrict fluid intake based on previous day's urine output -restrict fluid intake to 500-600 ml above 24hr urine output to prevent FVO, increased BP, and edema -measure weight and BP daily & report any increase in measurement -inform client that URINE can appear SMOKY, REDDISH-BROWN, RUST, or COLA COLOR -inform client to decrease Na intake to prevent FVO What are the nursing interventions/teaching for a client who has DEMENTIA? - -AVOID turning on the television in the evening b/c over-stimulation can disturb client's ability to fall asleep -limit # of choices about clothes to wear ( this can cause frustration and confusion). -place pictures of family on wall -USE PICTURES & GESTURES when giving instructions. Expected lab finding of ACUTE PANCREATITIS - -ELEVATED WBC (norm: 5,000- 10,000 mm3) -DECREASED Ca levels (norm: 9.0-10.5 mg/dL) -INCREASED AMAYLASE (norm is 30-220 units/L) Teachings of taking SILDENAFIL for Erectile Dysfunction (ED). - -instruct client to take med 30-4hr BEFORE sexual intercourse -monitor for DIZZINESS while on this med -take no more than ONCE PER DAY(adverse affect is PRIAPISM, HEARING LOSS, and MI). -explain to client that this drug can cause INSOMNIA rather the drowsiness. What can the nurse expect from a client who is at 35 weeks gestation and is experiencing PLACENTAL ABRUPT ION? - -OLIGURIA, secondary to hypovolemia -fundal height > than 34 cm -UTERINE HYPERTONICITY -HYPOTENSION What med(s) can the nurse expect to administer to a client that has GONORRHEA? - - CEFTRIAXONE (anitbiotic given IM) How should the nurse plan her care for a client who has PTSD? - -stay with client during flashbacks or nightmares to promote safety & sense of security -ASSIST client to IDENTIFY STAGE OF GRIEF -maintain a consistent care-giving staff -have client acknowledge and verbalize their feelings. What discharge teachings should the nurse include to the parents of a newborn who underwent a circumcision? - -do not remove yellow film (will fall off in 2-3 days) -apply diaper loosely -CLEAN PENIS with WARM WATER. -DO NOT use SOAP until 5-6 days after circumcision -report any signs of swelling b/c this could be a manifestation of INFECTION What medication can the nurse expect to administer for a client experiencing INFERTILITY? - -CLOMIPHENE (stimulates growth and release of eggs thus increasing chance of conception). What medication can the nurse expect to administer for a client experiencing GESTATION HTN? - -LABETOALOL (beta blocker that decreases BP) What medication can the nurse expect to administer for a client experiencing UTERINE ATONY? - -MISOPROSTOL (uterine oxytocin that causes contractions of uterine muscle). Manifestations of right-hemispheric stroke - -EUPHORIA -impaired visual-spatial perception -left sided neglect. -CONSTANT SMILING -impaired sense of humor -disorientation to time and place -inability to recognize familiar faces -loss of hearing -impulsiveness -denial of illness -lack of awareness Manifestations of left-hemispheric stroke - -right visual field defects -anxiety -low tolerance of frustration -DIFFICULTY READING -inability to discriminate letters and words -aphasia -memory deficits manifestations of chronic pancreatitis - -Tend to be insidious - Upper abdominal pain - Indigestion - Losing weight without trying - Steatorrhea (FOUL SMELLY BULKY STOOL) - Constipation - Flatulence -destruction of pancreatic islets may lead to diabetes--> resulting in HYPERGLYCEMIA discharge teachings for a patient in pre-term labor - -explain to the client that if contractions occur, DRINK 2-3 glasses of water (dehydration can lead to UTERINE CONTRACTIONS). -to report PAINLESS contractions to provider adverse effects of VALPROIC ACID - -Hepatotoxicity: liver failure (EX: YELLOW SCLERA) -Pancreatitis (check serum amylase) -Teratogenic effects -Indigestion & anorexia -hypothermia adverse effects of phenytoin - anti-epileptic med: -gingival hyperplasia (bleeding gums) -CNS effects -teratrogenic (cleft palate) adverse effects of diazepam - -benzodiazepine to manage status epilepticus -Sedation, psychological and physical dependence Newborn home safety teachings - tell parents of newborn to: -increase temp of room to 79-81 F to prevent hypothermia -not cover newborn with blankets while sleeping (increases risk of SIDS) -set the water heater temp to no more than 120 F (49 C) -place crib AWAY from heating vents, radiators, and portable space heaters. discharge teaching for placenta previa - explain to client that: -if any vaginal bleeding occurs, return to hospital IMMEDIATELY -do not place ANYTHING in their vaginas (no sexual intercourse) -must maintain BED REST only allowed to move for bathroom privileges -CLIENTS SHOULD HAVE CLOSE SUPERVISION and access to transportation manifestations of alcohol withdrawls - -hypertensive with in 12-72 hours of last drink -tachycardia with in 12-72 hours of last drink -disturbed sleep with in 12-72 hours of last drink -have mild TREMORS What increases a client's risk for developing Alzheimer's Disease (AD)? - -PRESENCE of APOLIPOPROTEIN E-4 gene -viruses (herpes zoster) -exposure to toxic metals like Zn or Cu -age (older than 60 yrs), gender (more common in women), and family history phases of battering (power and control wheel) - • Phase 1: Tensions build, Minor battering incidents occur and conflict builds • Phase 2: An explosive beating or otherwise abusive incident • Phase 3: Calm, Honeymoon phase as batterer often promises never to be abusive again teaching for managing fatigue of end-stage COPD - instruct client to: -walk at a self-pace rate & stop when fatigue occurs (rest-walk-rest until 20min is complete) -avoid eating dry foods b/c this will stimulate coughing thus causing fatigue -REST ELBOWS on table during activities -raise height of table to prevent back strain -sleep with head UPRIGHT to avoid DYSPNEA Instructions for epi-pen (auto-injector) - -carry pen in CLEAR PLASTIC CASE the manufacturer provides -use injector pen REGARDLESS OF SEVERITY of manifestations -inject epi-pen med THROUGH CLOTHING -expect medication to REMAIN CLEAR and not cloudy Instructions for epi-pen auto-injection for client with severe BEE ALLERGY - -inject medication IM into OUTER THIGH -hold for 10 sec, then massage injected area for 10 secs -monitor for adverse reactions like: NERVOUSNESS, PALPITATIONS, INCREASED PR, SWEATING, DIZZINESS, or HA. -Give a 2nd injection if 1st FAILS TO ENTIRELY REVERSE the reaction -store extra unused syringes AT ROOM TEMP. What indications shown by a client with OCD demonstrate that his/her therapy has been effective? - -client indicates that hey are more SOCIALLY INTERACTIVE -use of THOUGHT-STOPPING techniques -adhering to activity schedule -expect client to gradually spend less time completing ritualistic behaviors dietary management of HYPEREMISIS GRAVIDUM - -encourage dairy products b/c they mie be better tolerated. -consume foods at cold temps -avoid empty stomach by eating EVERY 2 HRS -consume SWEET FOODS FIRST, then protein-rich foods. How should the nurse provide safety for a newborn diagnosed with HYPERBILIRUBINEMIA and is undergoing PHOTOTHERAPY? - -apply opaque eye- shield on newborn -expose as much as the skin as possible this includes the scalp and trunk of the body. Teachings about disease management for client who has Parkinson's Disease - Instruct client to: -eat HIGH CALORIE MEALS which are HIGH in PROTEIN -schedule appointment LATER IN THE DAY -take meds at SAME TIME EACH DAY -instruct client to STAND UP STRAIGHT and look FORWARD Teachings on how to use bulb syringe on newborns - -COMPRESS the bulb FIRST, then insert syringe tip -SUCTION THE MOUTH FIRST, then each nare -INSERT tip of syringe on SIDE OF THE MOUTH. -DISCONTINUE suctioning when newborn's cry sounds are CLEAR. expected findings for client who has MELANOMA - -irregular shaped, colored papule with various colors expected findings for client who has ACTINIC KERATOSIS - -dry, scaly macule (malignant and occur on the UPPER BODY). expected findings for client who has SQUAMOUS CELL CARCINOMA - -nodular lesion with ulceration (malignant and occurs on SUN-EXPOSED areas of the UPPER BODY). expected findings for client who has BASAL CELL CARCINOMA - -pearly papule w/ waxy border (malignant and can occur on sun-exposed are of the BODY education planning about bullying - -children who are victims of bullying have an increased risk for depression, and more likely to attempt suicide. -victims of bullying behavior are at an increased risk for low self-esteem, feelings of insecurity, depression, and loneliness.