ATI NCLEX RATIONALES

ATI NCLEX RATIONALES

1.Cardiac dysrhythmias are a risk for clients taking haloperidol and other conventional antipsychotic medications. The client should be monitored for changes in vital signs, tachycardia, and ECG changes, including prolonged QT interval, while taking haloperidol. There is a risk for cardiac arrest due to torsades de pointes.

2.Body weight is the most reliable indicator of fluid loss for infants and young children.

3.Measles, mumps rubella (MMR) is correct. A 1-year-old child should receive the first of two doses of the MMR vaccine.Diphtheria, tetanus and acellular pertussis (DTaP) is incorrect. By 1 year of age, the child should have already received three doses of DTaP: at 2 months, 4 months, and 6 months. The child should receive a fourth dose at 15 months of age.Varicella (VAR) is correct. A 1-year-old child should receive the first of two doses of the VAR vaccine.Rotavirus (RV) is incorrect. A 1-year-old child should have received the RV vaccine in a two or three dose series starting at 2 months of age.Human papillomavirus (HPV4) is incorrect. A child should receive a three dose series of the HPV4 vaccine at 11 or 12 years of age.

4.The client has paralysis from the level of the defect down. In the majority of cases, this condition affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent emptying of the bladder can result in stasis and urinary tract infections.

5.Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.

6.Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal adverse effect of antipsychotic (haloperidol) medications that requires emergency medical intervention. Manifestations of NMS are sudden and include changes in level of consciousness, seizures, and stupor.

7.A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.

8.Any adult who has a respiratory rate of over 30/min requires immediate attention. Additionally, this patient is unconscious, which constitutes altered mental status. This client is the client he nurse should care for first.

9.Plan the client's schedule to allow time for rituals.

10.M YOCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels driven to perform. This behavior can be a physical action or a mental act that is aimed at neutralizing anxiety or distress. In the initial phase of treatment, the nurse should allow adequate time for the client to perform rituals to help the client handle anxiety.

11.Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation. 1 / 4

12.Noxious gas: Following the principle of mitigation, the nurse should facilitate evacuation out of the building to prevent exposure to the harmful gas and set up the triage site at a nearby location.

13.Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.

14.Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

15.Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

16.Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.

17.Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues.Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients.Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge, and the nails become extremely curved from front to back.

18.Rice, potatoes, and oranges 19.M Y A NSThis group of foods contains the highest level of carbohydrates.

20.What part of the exam makes you most nervous?" 21.M Y A NSWERThis therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns.

22.Red meat and organ meat 23.M Y A NSWERThis client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.

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23.a nurse is planning to teach a client about a low-potassium diet. Which of the following foods should the nurse instruct the client to avoid? Yogurt, Orange Juice

• Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure.

The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord.Polyuria is incorrect. The nurse should check the client for bladder distention and inability to urinate due to ineffective function of the bladder muscles.Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could 2 / 4

cause the client to develop a paralytic ileus.Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.

• A nurse is caring for a client who is admitted with acute psychosis and is being

treated with haloperidol (Haldol). The nurse should suspect that the client may be experiencing tardive dyskinesia as an adverse reaction when the client exhibits which of the following? (Select all that apply.) a)Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as tongue thrusting and lip smacking..Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as facial grimacing and eye blinking.Involuntary pelvic rocking and hip thrusting movements is correct. Repetitive, irregular, and involuntary movements of the head, neck, trunk, and extremities can occur in tardive dyskinesia.

• nurse is providing education about introducing new foods to the parents of a 4-

month-old infant. The nurse should recommend that the parents introduce which of the following foods first?Iron-fortified cereal should be the first solid food introduced to the infant.

• Pull the curtains around the client's bed: Pulling the curtains around the client's bed

assures privacy for the client should someone open the door or enter the room.

• Ask the client to describe the situation.WER

a.During the acute phase following assault, the nurse should encourage the client to provide information which may be helpful with treatment and to reduce the client’s anxiety.

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• A nurse accidentally administers the wrong medication to a client, which

results in a severe allergic reaction and prolongs the client’s hospitalization. The client could rightfully sue the nurse for which of the following? Malpractice The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client.

• A client on a mental health unit refuses treatment and asks to be

discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to prevent him from leaving the hospital. Restraining this client would be considered which type of civil action by the nurse? False imprisonment 3 / 4

• A nurse is admitting a child who has leukemia. Which of the following clients

should the nurse place in the same room with this child? A child who has nephrotic syndrome.

• A nurse is assessing a client who is 48 hr postoperative following

abdominal surgery. Which of the following findings should the nurse report to the provider?Yellow-green drainage on the surgical incision (yellow-green drainage is indicative of an infection).

• a nurse is providing dietary teaching to the parents of a newborn who is being

breastfed. The nurse should instruct that the transition to whole mill can occur which of the following ages? At the age of 12 moths.

37.A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?Shake the container vigorously. This ensures the particles of the medication are evenly distributed.

• A nurse is caring for a child who is admitted with suspected acute

appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? Sudden decrease in abdominal pain

• an older adult client who lives alone tells a clinic nurse that he is unable to

drive himself to the store and is afraid to cook on the stove. which of the following community resources should the nurse recommend for this client? Meals on wheel

• A nurse is instructing a group of adult clients about nutrition. The

nurse should include which of the following as the recommended amount of vegetables servings per day?

• 1/2 cups per day
• A nurse is caring for a client who has Cushing's syndrome. The nurse

should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.) Moon face alopecia Purple striations Buffalo hump

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