ATI CONCEPT BASED LEVEL 3 REVIEW
A nurse and I providers office is preparing immunizations for a 12 month old it but who is
immunocompromised. Which of the following immunizations should the nurse plan to administer at this
time?
Immunocompromised: no live vaccines!!!!!
Live vaccines: MMR, Varicella, rotavirus, flu.
So the nurse would give:
Hep B
Hib
PCV13
Hep A
A nurse is caring for a client who has schizophrenia. Which of the following statements made by the
client indicates delusions of reference?
Delusions of reference: they believe un-related occurrences have special significances
Ex: a secret message through newspaper
Delusions of grandeur: heightened sense of importance
Paranoia & delusions of control are also common in schizophrenic pts
A nurse is assessing a client who has epilepsy. The nurse should identify that which of the following
client statements indicates the pre-ictal phase of a seizure?
Answer: "suddenly smell a foul odor"
Pre: before- odors, taste, weird feelings
Tonic phase: stiffening/ rigidity
Post: can't remember/ amnesia
Partial seizure: may only affect one side
,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?
ABCs!!!!
Administer oxygen via non-rebreather facemask, suction as needed, monitor pulse oximetry, IV fluids,
magnesium sulfate, insert an indwelling catheter, and monitor vital signs, also place client in side lying
position
DO NOT: Adm ca+ gluconate it is for Mg toxicity
Adm fluid bolus it will lead to FVE
Place client in any position other than side
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of
obesity. Client statements indicates an understanding of teaching?
Answer: remain in a reclined position for 30 minutes after eating: these pts are at risk for dumping
syndrome reclining prevents dumping syndrome
Also: these pts do not have intrinsic factor anymore, meaning they can't absorb B12 therefore monthly
injections of B12 & iron are necessary
Also: pt needs to have puréed diet for min of 6 weeks
Also: keep skin folds dry and clean (no lotion)
A nurse in an acute care mental health unit is caring for a newly admitted client who has OCD. The client
is repeatedly washing her hands. Which of the following actions should the nurse take?
Answer: teach pt to use thought stopping techniques. physical activity & relaxation help as well
Also: give client a structured schedule
Also: meds for OCD include anxiolytics & SSRIs but use least invasive techniques first
,A nurse is assessing a client who has lung cancer. Which of the following manifestations should the
nurse expect?
Answer: persistent cough
Also: weight loss, should/arm/chest pain, & blood streaked or rust colored sputum (not clear)
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?
Answer: Apply a thin coating of lip balm to the client's lips.A client who is dying can experience
dehydration.
And:
Keep HOB elevated or on side if pt is N/V.
Let client rest/ sleep
Keep room dim
A nurse in an emergency department is assessing a client who is in a motor vehicle crash. The client who
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? Answer:
Denial: refused to acknowledge
Intellectualization: prevents thinking ab a situation
Rationalization: argues to excuse unacceptable behavior
Projection: puts his feelings on to another person
A nurse is providing teaching to the family of a client who has delirium. Which of the following
information should the nurse include?
Answer: delirium can be brought on by the stress
, Also: delirium develops quickly over hours or days
Delirium displays a wide range of emotions
Delirium can be reversed
An intensive care nurse is providing education about organ and tissue donation to the parent of an
adolescent who died following a crash. Which of the following responses by the parent indicates an
understanding of the teaching?
Answer: "no one will notice at funeral"
Must remain on life support to provide blood & O2
Corneas can be taken at TOD
Donation does not cost & does not require attorney
A nurse is teaching a client about obesity management. Which of the following information should the
nurse include?
Answer: walk 5 days a week for 30 minutes
Also: drink water, 1,200 cal/day, reward wt loss with non-food rewards
DO NOT DO: liquid diet programs
A nurse is caring for a client in active labor with a history of STI's. On examination the nurse notes a large,
cauliflower like cluster of lesions near the vagina. Which of the following actions should the nurse take?
Answer: Monitor the client for progressive fetal descent: HPV lesions can obstruct the birth canal and
impair fetal dissent
Also: The provider will discuss removal of the warts and lesions with cryotherapy
DO NOT do c-section: more dangerous for both
DO NOT USE PCN G
A nurse and I providers office is preparing immunizations for a 12 month old it but who is
immunocompromised. Which of the following immunizations should the nurse plan to administer at this
time?
Immunocompromised: no live vaccines!!!!!
Live vaccines: MMR, Varicella, rotavirus, flu.
So the nurse would give:
Hep B
Hib
PCV13
Hep A
A nurse is caring for a client who has schizophrenia. Which of the following statements made by the
client indicates delusions of reference?
Delusions of reference: they believe un-related occurrences have special significances
Ex: a secret message through newspaper
Delusions of grandeur: heightened sense of importance
Paranoia & delusions of control are also common in schizophrenic pts
A nurse is assessing a client who has epilepsy. The nurse should identify that which of the following
client statements indicates the pre-ictal phase of a seizure?
Answer: "suddenly smell a foul odor"
Pre: before- odors, taste, weird feelings
Tonic phase: stiffening/ rigidity
Post: can't remember/ amnesia
Partial seizure: may only affect one side
,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?
ABCs!!!!
Administer oxygen via non-rebreather facemask, suction as needed, monitor pulse oximetry, IV fluids,
magnesium sulfate, insert an indwelling catheter, and monitor vital signs, also place client in side lying
position
DO NOT: Adm ca+ gluconate it is for Mg toxicity
Adm fluid bolus it will lead to FVE
Place client in any position other than side
A nurse is providing discharge teaching to a client following gastric bypass surgery for management of
obesity. Client statements indicates an understanding of teaching?
Answer: remain in a reclined position for 30 minutes after eating: these pts are at risk for dumping
syndrome reclining prevents dumping syndrome
Also: these pts do not have intrinsic factor anymore, meaning they can't absorb B12 therefore monthly
injections of B12 & iron are necessary
Also: pt needs to have puréed diet for min of 6 weeks
Also: keep skin folds dry and clean (no lotion)
A nurse in an acute care mental health unit is caring for a newly admitted client who has OCD. The client
is repeatedly washing her hands. Which of the following actions should the nurse take?
Answer: teach pt to use thought stopping techniques. physical activity & relaxation help as well
Also: give client a structured schedule
Also: meds for OCD include anxiolytics & SSRIs but use least invasive techniques first
,A nurse is assessing a client who has lung cancer. Which of the following manifestations should the
nurse expect?
Answer: persistent cough
Also: weight loss, should/arm/chest pain, & blood streaked or rust colored sputum (not clear)
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?
Answer: Apply a thin coating of lip balm to the client's lips.A client who is dying can experience
dehydration.
And:
Keep HOB elevated or on side if pt is N/V.
Let client rest/ sleep
Keep room dim
A nurse in an emergency department is assessing a client who is in a motor vehicle crash. The client who
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? Answer:
Denial: refused to acknowledge
Intellectualization: prevents thinking ab a situation
Rationalization: argues to excuse unacceptable behavior
Projection: puts his feelings on to another person
A nurse is providing teaching to the family of a client who has delirium. Which of the following
information should the nurse include?
Answer: delirium can be brought on by the stress
, Also: delirium develops quickly over hours or days
Delirium displays a wide range of emotions
Delirium can be reversed
An intensive care nurse is providing education about organ and tissue donation to the parent of an
adolescent who died following a crash. Which of the following responses by the parent indicates an
understanding of the teaching?
Answer: "no one will notice at funeral"
Must remain on life support to provide blood & O2
Corneas can be taken at TOD
Donation does not cost & does not require attorney
A nurse is teaching a client about obesity management. Which of the following information should the
nurse include?
Answer: walk 5 days a week for 30 minutes
Also: drink water, 1,200 cal/day, reward wt loss with non-food rewards
DO NOT DO: liquid diet programs
A nurse is caring for a client in active labor with a history of STI's. On examination the nurse notes a large,
cauliflower like cluster of lesions near the vagina. Which of the following actions should the nurse take?
Answer: Monitor the client for progressive fetal descent: HPV lesions can obstruct the birth canal and
impair fetal dissent
Also: The provider will discuss removal of the warts and lesions with cryotherapy
DO NOT do c-section: more dangerous for both
DO NOT USE PCN G
