ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
orthostatic hypotension - - caused by Important teachings for client with new
DEHYDRATION from fluid loos and electrolyte prescription of a DIAPHRAGM. - - -should
imbalance remain in place for 6HR FOLLOWING
INTERCOURSE
-should remove diaphragm NO MORE THAN
gross motor skills - - physical abilities 24HRS following intercourse
involving large body movements, such as -insert diaphragm NO MORE THAN 6HR PRIOR
walking and jumping to intercourse
-EX: 9 month-old infant SHOULD be able to sit -apply about 10ml (2tsp) of SPERMICIDE inside
UNSUPPORTED for up to 10 MIN diaphragm prior to intercourse
-replace every 2 yrs.
-client should be refitted if their weight
Biofeedback - - technique that uses audio FLUCTUATE BY 20%
and visual signals that allow client to reduce -client should be refitted following a ABDOMINAL
muscle tension by gaining control over SURGERY, PELVIC SURGERY, & after each
autonomic physiologic functions. pregnancy
How should phenytoin be administered? Why? - A client with fibrocystic breast condition will... -
- -administered IV bolus at a rate no - have BREAST PAIN and tenderness as
greater than 50mg/min. well ass LUMPS usually in the UPPER OUTER
-to prevent HYPOTENSION and BRADYCARDIA QUADRANT of the breast.
Expected findings of INTRADUCTAL
Manifestations of Parkinson's Disease - -
tremor, rigidity, BRADYKINESIA, postural PAPILLOMA BREAST disorder? - - finding
instability, depression and other psychiatric will include:
changes, dementia, autonomic symptoms, sleep -mass in duct and NIPPLE DISCHARGE
disturbances
Expected findings of DUCTAL EXTASIS
Non-Hodgkin's Lymphoma - - spreads BREAST DISORDER? - - Enlarged axillary
ERRATICALLY through the LYMPHATIC nodes and Nipple discharge.
SYSTEM to other organs. It also manifest in
PAINLESS, swollen lymph nodes found in the
CERVICAL, AXILLLARY, INGUINAL, & Client with COPD will experience... - -
FEMORAL areas. DIGITAL CLUBBING, which DECREASES
arterial O2 levels.
Hodgkin's lymphoma - - spreads
SYSTEMICALLY from one group of lymph nodes tophi with chronic gout - - hard, painless
to the next group of nodes. nodule on first toe, collection of NA urate crystals
due to chronic gout, sometimes bursts with
chalky discharge
,ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
malignant tumor arising in bone; most often
occurring in children
Swan neck deformity - - -hyperextension of -client will experience pain in the UPPER THIGH
PIP joint and flexion of DIP joint as well as LOCALIZED PAIN, SWELLING, &
-late manifestation of RHEUMATOID ARTHRITIS PALPABLE MASS.
(RA)
What are expected findings of Multiple Sclerosis
scleroderma - - chronic progressive (MS)? - - -decrease visual acuity, diplopia,
disease of the skin and internal organs with changes in peripheral vision, & nystagmus
hardening and shrinking of connective tissue (repeat of uncontrolled movements).
-EXPECT flexion or contracture of joints. (late
manifestation)
What are expected finding of Amyotrophic Later
Sclerosis (ALS)? - - -fascifulcations of the
Preferred meal plan for a patient with face, twitching of the face or tongue.
DIVERTICULITIS - - -advance to high-fiber
diet. Best source of fiber is a BANANA which
yields 3.1g of FIBER. What is Amyotrophic Lateral Sclerosis (ALS)? -
- Also known an Lou Gherig's disease, ALS
is a motor neuron disease which can lead to
Diverticulitis - - inflammation of the paralysis.
diverticula
borderline personality disorder - - condition
What type of medication can increase a patient's marked by extreme instability in mood, identity,
risk for a stroke? - - -oral contraceptives and impulse control.
B/C this will INCREASE the risk for developing a -client's with this condition experience SUICIDAL
THROMBOEMBOLISM. IDEATION & SUBSTANCE ABUSE.
A client with HYPOPITUITARISM places the narcissistic personality disorder - -
them at risk for developing what type of characterized by a grandiose sense of self-
condition? - - -osteoporosis importance, a preoccupation with fantasies of
success or power, and a need for constant
attention or admiration or ARROGANCE
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 historonic personality disorder - - Impulsive
actually DECREASES the risk for stroke. attention seeking behavaior
What is Ewing Sarcoma? What are expected paranoid personality disorder - -A
manifestations of this disease? - - -rare personality disorder characterized by a pervasive
,ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
distrust and suspiciousness of the motives of
others without sufficient basis
Immunization schedule - - Birth: Hep B
What are some complications of an infant born at 2 mos: Hep B, ROTAVIUS, DTaP, Hib,
or less than 32 weeks? - - -apnea Pneumococcal, Poliovirus
-nectrotizing enterocolitis (due to intestinal
ischemia and immature immune system) 4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus
-hypoglycemia
-anemia 6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus
-polycythemia
-hypothermia 12 mos: MMR, VAR, Hep A, Influenza, Hib
11-12 YEARS: Tdap, Meningococcal, HPV
What teachings should the nurse include for a
client that underwent a UTERINE ARTERY
EMBOLIZATION? - - -client may ADHD (Attention-Deficit Hyperactivity Disorder) -
experience flu-like symptoms for 7 days after - a psychological disorder marked by
procedure (embolectomy syndrome) extreme inattention and/or hyperactivity and
-inform client that a CLOSURE DEVICE or impulsivity
INJECTION that blocks blood flow to the arteries
of the FIBROID TUMOR is used
-inform client that SEVERE CRAMPING may What should the nurse include in her planning for
occur in the first 24hr after the procedure and a patient who has ACUTE phase of
can last up to 2 weeks. DIVERTICULITIS? - - -Instruct the client to
AVOID COUGHING (this can increase the intra-
abdominal pressure and cause BOWEL
What teachings should the nurse include for a PERFORATION).
client who has bipolar disorder and has a new -ADMINISTER OPIOID analgesics to relieve pain
prescription of LITHIUM? - - -instruct client (this can decrease bowel motility)
to take Li with meals to decrease irritation of -DO NOT administer EMEMAS or LAXITIVES
gastric mucosa. (this will increase bowel motility and places client
-maintain adequate intake of salt (low Na can at risk for bowel perforation)
lead to Li retention, which can cause Li toxicity). -client should be NPO or on a clear liquid diet
-drink at least 1.5-3L of fluids each day (this will decrease inflammation of the bowels).
(dehydration can lead to Li toxicity).
-expect WEIGHT GAIN (common adverse effect
of Li). sickle cell crisis - - condition in sickle cell
anemia in which the sickled cells interfere with
oxygen transport, obstruct capillary blood flow,
Autism Spectrum Disorder (ASD) - -A and cause fever and severe pain in the joints and
disorder characterized by deficits in social abdomen.
relatedness and communication skills that are
often accompanied by repetitive, ritualistic
behavior. How should the nurse manage care for a client
, ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
who is experiencing a sickle cell crisis? - - -provide soothing music, use therapeutic touch,
-promote fluid intake to prevent dehydration and keep noise level low
-monitor peripheral capillary refill, pulse O2, and -don place heating pads on extremities
skin temp every 1hr to assess PERFUSION of
EXTREMITIES.
-EXTEND client's knees to promote perfusion of What teachings should the nurse include to a
lower extremities. client who is preclamtic WITHOUT severe
-elevate head or bed to 30 DEGREES or less to features? - - -inform client to use SIDE-
increase perfusion to lower extremities. LYING POSITION when resting in bed or on
couch
-monitor blood pressure 2 times a week
What are the depressive manifestation of low
self-esteem? - - -hypersensitivity to
criticism What teachings should the nurse include to a
-guilt client who is preclamtic WITH severe features? -
-shame - -limit fluid intake to PREVENT
-expression of helplessness PULMONARY EDEMA
-lack of eye contact -maintain a DARK, QUIET ENVIRONMENT to
-pessimistic outcome on life avoid stimuli that can cause seizure activity.
What are the manifestations of spiritual distress?
How should the nurse plan her care to a client
- - -express lack of meaning in life with anorexia nervosa? - - -observe client
-anger for 60 MIN AFTER MEALS
-refusing interactions with family -weigh client each day early in the morning after
-discontinuing spiritual practice voiding, while wearing the same amount of
clothing each day.
-EMPHASIZE SOCIAL ASPECTS of eating
What are the manifestations of disturbed thought during mealtimes.
process? - - -impaired problem-solving
skills
-confusion What drug may cause an adverse affect when
-difficulty concentration combined with METAMINE? - - -SODIUM
-inappropriate thinking BICARBONATE (antacid used to treat GI upset)
-memory deficits b/c this can increase accumulation of METAMINE
which can lead to TOXICITY
What are the nursing interactions for palliative
care of near death clients? - - -administer Teachings for client who has genital herpes -
analgesics like morphine SUB Q, SUBLINGUAL, - -wear gloves when applying anesthetic
or IV if the client is NOT RESPONSIVE. ointment
-APPLY A SOCOPALAMINE TRANSDERMAL -begin ORAL ANTIVIRALS with in 1 day of
PATCH or administer ATROPINE to decrease outbreak
oral or respiratory secretions. -use latex or plyurethane condoms during sexual
Complete Solutions
orthostatic hypotension - - caused by Important teachings for client with new
DEHYDRATION from fluid loos and electrolyte prescription of a DIAPHRAGM. - - -should
imbalance remain in place for 6HR FOLLOWING
INTERCOURSE
-should remove diaphragm NO MORE THAN
gross motor skills - - physical abilities 24HRS following intercourse
involving large body movements, such as -insert diaphragm NO MORE THAN 6HR PRIOR
walking and jumping to intercourse
-EX: 9 month-old infant SHOULD be able to sit -apply about 10ml (2tsp) of SPERMICIDE inside
UNSUPPORTED for up to 10 MIN diaphragm prior to intercourse
-replace every 2 yrs.
-client should be refitted if their weight
Biofeedback - - technique that uses audio FLUCTUATE BY 20%
and visual signals that allow client to reduce -client should be refitted following a ABDOMINAL
muscle tension by gaining control over SURGERY, PELVIC SURGERY, & after each
autonomic physiologic functions. pregnancy
How should phenytoin be administered? Why? - A client with fibrocystic breast condition will... -
- -administered IV bolus at a rate no - have BREAST PAIN and tenderness as
greater than 50mg/min. well ass LUMPS usually in the UPPER OUTER
-to prevent HYPOTENSION and BRADYCARDIA QUADRANT of the breast.
Expected findings of INTRADUCTAL
Manifestations of Parkinson's Disease - -
tremor, rigidity, BRADYKINESIA, postural PAPILLOMA BREAST disorder? - - finding
instability, depression and other psychiatric will include:
changes, dementia, autonomic symptoms, sleep -mass in duct and NIPPLE DISCHARGE
disturbances
Expected findings of DUCTAL EXTASIS
Non-Hodgkin's Lymphoma - - spreads BREAST DISORDER? - - Enlarged axillary
ERRATICALLY through the LYMPHATIC nodes and Nipple discharge.
SYSTEM to other organs. It also manifest in
PAINLESS, swollen lymph nodes found in the
CERVICAL, AXILLLARY, INGUINAL, & Client with COPD will experience... - -
FEMORAL areas. DIGITAL CLUBBING, which DECREASES
arterial O2 levels.
Hodgkin's lymphoma - - spreads
SYSTEMICALLY from one group of lymph nodes tophi with chronic gout - - hard, painless
to the next group of nodes. nodule on first toe, collection of NA urate crystals
due to chronic gout, sometimes bursts with
chalky discharge
,ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
malignant tumor arising in bone; most often
occurring in children
Swan neck deformity - - -hyperextension of -client will experience pain in the UPPER THIGH
PIP joint and flexion of DIP joint as well as LOCALIZED PAIN, SWELLING, &
-late manifestation of RHEUMATOID ARTHRITIS PALPABLE MASS.
(RA)
What are expected findings of Multiple Sclerosis
scleroderma - - chronic progressive (MS)? - - -decrease visual acuity, diplopia,
disease of the skin and internal organs with changes in peripheral vision, & nystagmus
hardening and shrinking of connective tissue (repeat of uncontrolled movements).
-EXPECT flexion or contracture of joints. (late
manifestation)
What are expected finding of Amyotrophic Later
Sclerosis (ALS)? - - -fascifulcations of the
Preferred meal plan for a patient with face, twitching of the face or tongue.
DIVERTICULITIS - - -advance to high-fiber
diet. Best source of fiber is a BANANA which
yields 3.1g of FIBER. What is Amyotrophic Lateral Sclerosis (ALS)? -
- Also known an Lou Gherig's disease, ALS
is a motor neuron disease which can lead to
Diverticulitis - - inflammation of the paralysis.
diverticula
borderline personality disorder - - condition
What type of medication can increase a patient's marked by extreme instability in mood, identity,
risk for a stroke? - - -oral contraceptives and impulse control.
B/C this will INCREASE the risk for developing a -client's with this condition experience SUICIDAL
THROMBOEMBOLISM. IDEATION & SUBSTANCE ABUSE.
A client with HYPOPITUITARISM places the narcissistic personality disorder - -
them at risk for developing what type of characterized by a grandiose sense of self-
condition? - - -osteoporosis importance, a preoccupation with fantasies of
success or power, and a need for constant
attention or admiration or ARROGANCE
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 historonic personality disorder - - Impulsive
actually DECREASES the risk for stroke. attention seeking behavaior
What is Ewing Sarcoma? What are expected paranoid personality disorder - -A
manifestations of this disease? - - -rare personality disorder characterized by a pervasive
,ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
distrust and suspiciousness of the motives of
others without sufficient basis
Immunization schedule - - Birth: Hep B
What are some complications of an infant born at 2 mos: Hep B, ROTAVIUS, DTaP, Hib,
or less than 32 weeks? - - -apnea Pneumococcal, Poliovirus
-nectrotizing enterocolitis (due to intestinal
ischemia and immature immune system) 4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus
-hypoglycemia
-anemia 6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus
-polycythemia
-hypothermia 12 mos: MMR, VAR, Hep A, Influenza, Hib
11-12 YEARS: Tdap, Meningococcal, HPV
What teachings should the nurse include for a
client that underwent a UTERINE ARTERY
EMBOLIZATION? - - -client may ADHD (Attention-Deficit Hyperactivity Disorder) -
experience flu-like symptoms for 7 days after - a psychological disorder marked by
procedure (embolectomy syndrome) extreme inattention and/or hyperactivity and
-inform client that a CLOSURE DEVICE or impulsivity
INJECTION that blocks blood flow to the arteries
of the FIBROID TUMOR is used
-inform client that SEVERE CRAMPING may What should the nurse include in her planning for
occur in the first 24hr after the procedure and a patient who has ACUTE phase of
can last up to 2 weeks. DIVERTICULITIS? - - -Instruct the client to
AVOID COUGHING (this can increase the intra-
abdominal pressure and cause BOWEL
What teachings should the nurse include for a PERFORATION).
client who has bipolar disorder and has a new -ADMINISTER OPIOID analgesics to relieve pain
prescription of LITHIUM? - - -instruct client (this can decrease bowel motility)
to take Li with meals to decrease irritation of -DO NOT administer EMEMAS or LAXITIVES
gastric mucosa. (this will increase bowel motility and places client
-maintain adequate intake of salt (low Na can at risk for bowel perforation)
lead to Li retention, which can cause Li toxicity). -client should be NPO or on a clear liquid diet
-drink at least 1.5-3L of fluids each day (this will decrease inflammation of the bowels).
(dehydration can lead to Li toxicity).
-expect WEIGHT GAIN (common adverse effect
of Li). sickle cell crisis - - condition in sickle cell
anemia in which the sickled cells interfere with
oxygen transport, obstruct capillary blood flow,
Autism Spectrum Disorder (ASD) - -A and cause fever and severe pain in the joints and
disorder characterized by deficits in social abdomen.
relatedness and communication skills that are
often accompanied by repetitive, ritualistic
behavior. How should the nurse manage care for a client
, ATI RN Concept-Based Assessment Level 3 Study Guide with
Complete Solutions
who is experiencing a sickle cell crisis? - - -provide soothing music, use therapeutic touch,
-promote fluid intake to prevent dehydration and keep noise level low
-monitor peripheral capillary refill, pulse O2, and -don place heating pads on extremities
skin temp every 1hr to assess PERFUSION of
EXTREMITIES.
-EXTEND client's knees to promote perfusion of What teachings should the nurse include to a
lower extremities. client who is preclamtic WITHOUT severe
-elevate head or bed to 30 DEGREES or less to features? - - -inform client to use SIDE-
increase perfusion to lower extremities. LYING POSITION when resting in bed or on
couch
-monitor blood pressure 2 times a week
What are the depressive manifestation of low
self-esteem? - - -hypersensitivity to
criticism What teachings should the nurse include to a
-guilt client who is preclamtic WITH severe features? -
-shame - -limit fluid intake to PREVENT
-expression of helplessness PULMONARY EDEMA
-lack of eye contact -maintain a DARK, QUIET ENVIRONMENT to
-pessimistic outcome on life avoid stimuli that can cause seizure activity.
What are the manifestations of spiritual distress?
How should the nurse plan her care to a client
- - -express lack of meaning in life with anorexia nervosa? - - -observe client
-anger for 60 MIN AFTER MEALS
-refusing interactions with family -weigh client each day early in the morning after
-discontinuing spiritual practice voiding, while wearing the same amount of
clothing each day.
-EMPHASIZE SOCIAL ASPECTS of eating
What are the manifestations of disturbed thought during mealtimes.
process? - - -impaired problem-solving
skills
-confusion What drug may cause an adverse affect when
-difficulty concentration combined with METAMINE? - - -SODIUM
-inappropriate thinking BICARBONATE (antacid used to treat GI upset)
-memory deficits b/c this can increase accumulation of METAMINE
which can lead to TOXICITY
What are the nursing interactions for palliative
care of near death clients? - - -administer Teachings for client who has genital herpes -
analgesics like morphine SUB Q, SUBLINGUAL, - -wear gloves when applying anesthetic
or IV if the client is NOT RESPONSIVE. ointment
-APPLY A SOCOPALAMINE TRANSDERMAL -begin ORAL ANTIVIRALS with in 1 day of
PATCH or administer ATROPINE to decrease outbreak
oral or respiratory secretions. -use latex or plyurethane condoms during sexual
