ATI BOARD VITALS - A nurse is providing teaching about Hep. A with...

ATI BOARD VITALS

Question 1: Difficulty level- Moderate

A nurse is providing teaching about Hep. A with a client who plans to travel. Which of the following statements should the nurse make?A.If exposed, expect to have manifestation within 10 days B.Avoid donating blood or tissue for one year if you develop the infection C.Practice meticulous skin and hand hygiene D.Expect if you are exposed to have severe joint pain

ANSWER: C. Practice meticulous skin and hand hygiene

The nurse should instruct the client to always wash hands before eating and after using the toilet, because Hep. A is an active virus that is transmitted by hands or areas of the skin that have been in contact with infected feces. Effective skin and hand hygiene and ensuring a safe water supply are the most effective strategies for preventing the transmission of hepatitis.

Incorrect Answers:

1.the nurse should include the teaching that if exposed to Hep. A, manifestations develop in 15 to 50 days after exposure 2.the nurse should inform the client that, due to the hepatitis A infection after age 11, they may not be able to donate blood, body tissue, or organs.

3.The nurse should include in the teaching that manifestations of Hepatitis A are similar to gastrointestinal illness with an uneventful recovery. Hep. B causes joint pain, not Hep. A.Vital Concept Actions that can be taken to prevent the transmission of hep. A include the following: I.Receive immunoglobulin within 2 weeks of exposure II.Use strict skin and hand washing, especially after touching shellfish III.Avoid contaminated drinking water or foods IV.Get the hep. A vaccine prior to traveling outside of the U.S. or to areas experiencing Hep.A outbreaks Question 2 The nurse is assigning clients on a medical-surgical floor. Which clients listed below are appropriate to assign to an licensed vocation nurse (LVN)? SATA A.A client 3 days after abdominal aortic aneurysm repair who is stable B.A client 3 days after hip replacement C.A client who was admitted six hours ago with an acute asthma exacerbation D.A client who was admitted twelve hours ago with gastrointestinal bleeding E.A client admitted with nausea and vomiting two days ago who no long has nausea and/or vomiting

ANSWER: A. A client 3 days after abdominal aortic aneurysm repair who is stable

• A client 3 days after hip replacement
• A client admitted with nausea and vomiting two days ago who no longer is

All of these clients are stable and not expected to change. It is appropriate to assign their care to an LVN

Incorrect Answers: C, D

This client would not be appropriate to be assigned to the LVN. This client’s condition is likely to change rapidly and will require ongoing assessment This client would not be appropriate to be assigned to the LVN. This client’s condition is not considered stable and will require ongoing assessment.Vital Concept The nurse should be aware of appropriate delegation principles. Doing so will ensure client safety and decrease nurse liability.

Question 3: Difficulty level- hard

A nurse is assigned to. Newly admitted client on a psychiatric unit. When discussing the client’s condition and treatment plan, which of th4e following techniques is most appropriate for the nurse to assess the accuracy of interpretation of the client’s words?A.Presuppositions question B.Open-ended question C.Paraphrasing D.Focusing

ANSWER: C. Paraphrasing

A variety of communication techniques can be used by nurses in the therapeutic relationship with a client. It is important for a nurse who is caring for clients with significant mental health disorders to be aware that extra time may be necessary while awaiting response. The nurse should use behaviors that convey interests, respect, and a caring attitude. Questions are used to obtain important information from the client. Clarifying techniques such as reflecting, restating, or paraphrasing can be sued to assess the client’s understanding of the nurse’s message.

Incorrect Answers:

• Presupposition question are questions with hypothetical situation that are used to explore

the client’s motivation.

• Open-ended questions are used to facilitate discussion and allow the client to express

feelings and concerns.

• Focusing is used to assist the client in concentrating on important messages.

Vital Concept:

Use of clarifying communication techniques may be necessary for a nurse to confirm accurate understanding goa client with a mental health disorder. The. nurse can restate or paraphrase the client’s message to determine if the meaning was correctly interpreted by the nurse.Question 4 Which factor is most likely a risk associated with developing urinary incontinence?A.Insomnia B.History of multiple pregnancies C.Gastroesophageal reflux disease D.Orthostatic hypotension

ANSWER: B. History of multiple pregnancies

A client who has been pregnant multiple times would be more likely to have weakening of the pelvic floor muscles, which would contribute to urinary incontinence.

Incorrect Answers:

A.Insomnia is typically not related to an increased risk of urinary incontinence

• Gastroesophageal reflux disease does not impact the urinary system. Constipation or fecal

impaction can increase the risk for urinary incontinence

• Orthostatic hypotension may be a factor in some people who are immobile and have

urinary incontinence, but it is not a cause of development of the condition.

Vital Concept:

Stress urinary incontinence (UI) is defined as an involuntary loss of urine associated with activities that increase intra-abdominal pressure. Urge UI is characterized by involuntary urine loss associated with urinary urgency. UI may be the result of mixed stress and urge incontinence. A client with overactive bladder may complain of urinary urgency, with or without UI.Question 5 The nurse assesses a 6-month old for vaccination readiness, which findings would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (dTaP)?A.A family history of sudden infant death syndrome (SIDS) B.fever of 38.5 degrees following the 4-month vaccination C.An acute bilateral ear infection D.Living with a family member who is immunosuppressed

ANSWER: C. An acute bilateral ear infection

Vaccination in the presence of a moderate to severe infection, with or without fever, increased the risk of injury and decrease the chance of mounting a strong immune response to the vaccine.

Incorrect Answers:

• there is currently no evidence to suggest vaccines raise the risk of SIDS. A mild fever may be

expected with the DTaP.

• A fever of greater than 40.5C within 48 hours of vaccination would warrant caution. The DTaP

is not a live vaccine.

• No special precautions are needed regarding immunosuppressed family members.

Vital Concept:

Children with a minor illnesses may be vaccinated, but children wo are moderately or severely ill should wait until they recover before getting DTaP vaccine DTaP vaccine should not be given to a child who has had a life-threatening allergic reaction after a dose of DTaP or who experienced a brain or nervous system disease within 7 days after a dose of DTaP.Question 6 A nurse is speaking with the parents of a child who has been the victim of bullying. Which of the following is true?A.Children who are victims of bullying are eager to confide in an adult B.Physical bullying is more common than verbal bullying C.Bullying is a normal part of childhood growth and development D.A physical disability is associated with a higher risk of bullying

ANSWER: D. A physical disability is associated with a higher risk of bullying.

Bullying refers to repetitive intentional infliction of physical, psychological, or emotional abuse by one or more individuals upon another individual who is deemed less physical or psychologically powerful than the bully. Bullying is not a normal part of childhood growth and development. Children generally want to conform to their peer group, beginning in middle childhood, and some may be unable to do so, preventing peer identification. This increases the risk of being bullied, particularly in children with disabilities or unusual physical characteristics.LT consequences of bullying include sleep disturbances, adjustment disorders, anxiety and depression. Bullied children may also develop anxiety, feelings of insecurity, psychosomatic complaints, and poor academic performance.

Incorrect Answers:

• Children who are bullied are frequently ashamed of being perceived as week or afraid to

confide in an adult because of concerns of reprisal.