ATI comprehensive final exam

ATI comprehensive final exam A nurse in an emergency department completes an assessment on an adolescent client that has conduct disorder. The client threatened suicide to teacher at school. Which of the following statements should the nurse include in the assessment? a) Tell me about your siblings b) Tell me what kind of music you like c) Tell me how often do you drink alcohol d) Tell me about your school schedule c) Tell me how often do you drink alcohol *A nurse is observing bonding to the client her newborn. Which of following actions by the client requires the nurse to intervene? a) Holding the newborn in an en face position b) Asking the father to change the newborn's diaper c) Requesting the nurse take the newborn nursery so she can rest d) Viewing the newborn's actions to be uncooperative d) Viewing the newborn's actions to be uncooperative A nurse is caring for client who is taking levothyroxine. Which of the following findings should indicate that the medication is effective? a) Weight loss b) Decreased blood pressure c) Absence of seizures d) Decrease inflammation a) Weight loss (this drug acts as T4 and will normalize the effects of hypothyroidism) A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching? a) Contact provider if the cord still turns black b) Clean the base of the cord with hydrogen peroxide daily c) Keep the cord dry until it falls off d) The cord stump will fall off in five days c) Keep the cord dry until it falls off a) Contact provider if the cord still turns black (it's going to turn black) b) Clean the base of the cord with hydrogen peroxide daily (clean with neutral pH cleanser) c) Keep the cord dry until it falls off (cord should be kept clean and dry to prevent infection) d) The cord stump will fall off in five days (cord falls off in 10-14 days A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? a) Shivering b) Oliguria c) Bradypnea d) Constricted pupil b) Oliguria A nurse is assisting with mass casualty triage: explosion at a local factory. Which of the following client should the nurse identify as the priority? a) A client that has massive head trauma b) A client has full thickness burns to face and trunk c) A client with indications of hypovolemic shock d) A client with open fracture of the lower extremity c) A client with indications of hypovolemic shock A nurse is a receiving report on four clients. Which of the following clients should the nurse assess first? a) A client who has illeal conduit and mucus in the pouch b) Client pleasant arteriovenous additional vibration palpated c) A client whose chronic kidney disease with cloudy dialysate outflow d) A client was transurethral resection of the prostate with a red tinged urine in the bag c) A client whose chronic kidney disease with cloudy dialysate outflow A nurse is caring for a client just received the first dose of lisinopril. The following is an appropriate nursing intervention? a) Place's cardiac monitoring b) Monitor the clients oxygen saturation level c) Provide standby assist with the client from bed d) Encourage foods high in potassium c) Provide standby assist with the client from bed A nurse is caring for a client who is in labor and his seat is receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which the following should the nurse expect? a) Feta hypoxia b) Abrupto placentae c) Post maturity d) Head Compression d) Head Compression A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as in an indication for hemodialysis? a) glomerular filtration rate of 14 mL/ minute b) BUN 16 mg/DL c) serum magnesium 1.8 mg mg/dl d) Serum phosphorus 4.0 mg/dL a) glomerular filtration rate of 14 mL/ minute A nurse is caring for an infant who has a prescription for continuous pulse oximetry. The following is an appropriate action for the nurse to take? a) Placed infant under radiant warmer b) Move the probe site every 3 hours c) Heat the skin one minute prior to placing the program d) Placed a sensor on the index finger c) Heat the skin one minute prior to placing the program A nurse in a mental health facility receives a change of shift report on for clients. Which of the following clients should the nurse plan to assess first? a) Client placed in restraints to the aggressive behavior b) A new limited client pleasures history of 4.5 kg weight loss in the past two months c) Client is receiving a PRN dose of health heard all two hours ago for increased anxiety d) Applied he'll be receiving his first ECT treatment today a) Client placed in restraints to the aggressive behavior A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following statements by the nurse is an appropriate description of the use of hypnosis during labor? a) Hypnosis focuses on the biofeedback as a relaxation technique b) Hypnosis promotes increased control of her pain perception during contractions c) Hypnosis uses therapeutic touch to reduce anxiety during labor d) Hypnosis provides instruction to minimize pain b) Hypnosis promotes increased control of her pain perception during contractions 14) A nurse in a County Jail health clinic is leading group therapy session. A client who was incarcerated for theft is addressing the group. Which of the following is an example of reaction formation? a) I steal things because it's the only way I can keep my mind off my bad marriage b) I can't believe I was accused of something I didn't do c) I don't want talk about my feelings right now. We will talk more next time d) I think that people just you're just lazy and should earn money honestly d) I think that people just you're just lazy and should earn money honestly (reaction formation is when you use opposite feelings; ex: being super nice to someone you dislike) A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to medication? a) Glaucoma b) Hypertension c) Polycythemia d) Migraine headaches a) Glaucoma The nurses is caring for a client recovering from an acute myocardial infarction. Which following intervention should the nurse include in the point of care? a) Draw a troponin level every four hours b) Performance EKG every 12 hours c) Plant oxygen tent fell over minutes via rebreather mask d) Obtain a cardiac rehabilitation consult d) Obtain a cardiac rehabilitation consult A Nurses caring for client who has breast cancer and has been covering receiving chemotherapy. Which of the following laboratory values should nurse report to provider? a) WBC 3,000/mm3 b) Hemoglobin 14 g/dl c) Platelet 250,000/mm3 d) aPTT 30 seconds a) WBC 3,000/mm3 Home health nurse is carefully planned for Alzheimer's disease. To the following action should the nurse include in the plan of care? a) Place a daily calendar in the kitchen b) Replace button clothing with zippered items c) Replace the carpet with hardwood floors d) Create variation in daily routine a) Place a daily calendar in the kitchen Nurse is performing change of shift assessments on 4 clients. Which of the following findings should the nurse report to provider first? a) The client was cystic fibrosis and has a thick productive cough and reports thirst b) Client who has gastroenteritis and is lethargic and confused c) The Client has diabetes mellitus has morning fasting blood glucose of 185 mg d) The client was sick of signing it reports pain 15 minutes after receiving oral analgesic b) Client who has gastroenteritis and is lethargic and confused A nurse is caring for a client was in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate? a) Decrease taking vitamins and supplements to every other day b) Eat 15 g of fiber per day