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ATI CRITICAL THINKING EXAM

Teacher 40 terms diana_peralta898 Preview 75 Free 75 terms car The student nurse is instructed by the registered nurse to monitor a dark-skinned client for cyanosis. The registered nurse determines that the student needs further teaching regarding physical assessment techniques for the dark- skinned client if the student states that the beterm-0st area to assess for cyanosis is where?1) lips 2) tongue 3) nail beds 4) sclera of the eye 4) Sclera of the eye A client has a newly fractured fibula that was plaster casted in the emergency department. Because the client will need to use crutches, which crutch-walking gait should the nurse teach the client before discharge?1) two point gate 2) three point gate 3)swing through gate 4)four point alternate gait 2) three point gate The nursing student is assigned to care for a client with a documented diagnosis of presbycusis. Which documentation on the psychosocial assessment should the nursing student expect to note? Select all that apply 1) acting out 2) manipulation 3) improvement 4) attention seeking 3) improvement

The nursing student is assigned to care for a client with a documented diagnosis of presbycusis. Which documentation on the psychosocial assessment should the nursing student expect to note? Select all that apply.1) The client may isolate herself or himself.2)The client has a sensorineural hearing loss.3) The client has difficulty with communication.4) The client may demonstrate signs and symptoms of depression.5) The client has positive Rinne and Webber test with lateralization to the left ear.

ans: 1, 3, 4

1) The client may isolate herself or himself.3) The client has difficulty with communication.4) The client may demonstrate signs and symptoms of depression.A client is suspected of having pulmonary tuberculosis (TB). The nurse assesses the client for which manifestations of this communicable disease? Select all that apply.1) Hematuria 2) Chest pain 3) Hemoptysis 4) Night sweats 5) High fever at night

ans: 2, 3, 4

2) Chest pain 3) Hemoptysis 4) Night sweats The client with pulmonary TB generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.The nurse recognizes which signs as indications that a client who recently experienced a myocardial infarction (MI) may be developing cardiogenic shock?1) Oliguria, bradypnea, and warm dry skin 2) Tachycardia, confusion, and hypotension 3) Bradycardia, hypertension, and a pale appearance 4) Peripheral edema, distended neck veins, and hepatic engorgement

ans: 2

2) Tachycardia, confusion, and hypotension

classical s/s of cardiogenic shock include:

tachycardia, confusion, hypotension, tachypnea, oliguria, and cold/clammy/cyanotic skin.Which questions should the nurse ask the client when assessing for indicators of possible cataract development? Select all that apply.

1."Do you wear contact lenses?" 2."How old were you on your last birthday?" 3."Have you ever been prescribed corticosteroids?" 4."Do you wear sunglasses regularly when you are outdoors?" 5."Have you ever experienced any injury to either of your eyes?"

ans: 2, 3, 4, 5

2."How old were you on your last birthday?" 3."Have you ever been prescribed corticosteroids?" 4."Do you wear sunglasses regularly when you are outdoors?" 5."Have you ever experienced any injury to either of your eyes?"

The nurse is caring for an intubated client on mechanical ventilation and the low-pressure alarm sounds. Which interventions should the nurse implement to determine the cause of the alarm? Select all that apply.1) Assess the endotracheal tube for a cuff leak.2) Look for any disconnections in the ventilator circuit.3) Check for a kink or water in the ventilator circuit tubing.4) Determine if the client is anxious or fighting the ventilator.5) Check to see if the client is biting on the endotracheal tube.

ans: 1, 2

1) Assess the endotracheal tube for a cuff leak.2) Look for any disconnections in the ventilator circuit.The low-pressure alarm sounds when there is a leak in the client's artificial airway cuff or a disconnection or leak in the ventilator circuit. The remaining options address problems with the client or ventilator that would cause the high-pressure alarm to sound.The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply.1) Obtaining an informed consent for a surgical procedure 2) Providing information necessary for a client to make informed decisions 3) Providing assistance in asserting the client's human and legal rights if the need arises 4) Including the client's religious or cultural beliefs when assisting the client in making an informed decision 5) Defending the client's rights by speaking out against policies or actions that might endanger the client's well- being

ans: 2, 3, 4, 5

2) Providing information necessary for a client to make informed decisions 3) Providing assistance in asserting the client's human and legal rights if the need arises 4) Including the client's religious or cultural beliefs when assisting the client in making an informed decision 5) Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family?1) Inform the friend to directly contact the family and offer assistance to them.2) Request that the friend come to the client's home during the next home health visit.3) Report the friend's call to the nurse manager for referral to the client's social worker.4) Assure the friend that there is no need for assistance since the nurse is visiting daily.

ans: 1

1) Inform the friend to directly contact the family and offer assistance to them.

A client has decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow. The nurse determines that the client's condition is improved if which data are obtained on assessment of the client?1) Dyspnea while ambulating to the bathroom is reduced.2) Presence of fine bibasilar lung crackles on auscultation is noted.3) Oxygen saturation is increased from 82% to 88% by pulse oximeter. 4) O2 level is increased to 90 mm Hg from 76 mm Hg, and CO2 level is decreased to 43 mm Hg from 54 mm Hg.

ans: 4

4) O2 level is increased to 90 mm Hg from 76 mm Hg, and CO2 level is decreased to 43 mm Hg from 54 mm Hg.Signs and symptoms that correlate with decreased pulmonary perfusion include dyspnea and hypoxia, making options 1 and 3 incorrect. Crackles indicate fluid in the alveoli, which impairs gas exchange at the alveolar level, making option 2 incorrect.A nursing student is assigned to care for a child who has been placed in Crutchfield tongs to stabilize a fracture in the cervical area. The registered nurse reviews the plan of care created by the student and decides there is a need for further teaching if which intervention is included?1) Monitor neurological status.2) Perform pin care every shift.3) Logroll the child when positioning. 4) Check the tongs every 24 hours for displacement and looseness.

ans: 4

4) Check the tongs every 24 hours for displacement and looseness.The purpose of Crutchfield tongs is to stabilize fractures or displaced vertebrae in the cervical and thoracic areas. Tongs are inserted on the sides of the scalp through drill holes. Traction pull is always along the axis of the spine. The nurse should check the tongs at least every 8 hours and as needed (PRN) for displacement and looseness. Neurological status should be checked frequently, because spinal cord injury frequently accompanies a cervical injury. Pin care is done every shift. The child can be repositioned by logrolling or turned as a unit.The nurse is measuring the head circumference of an infant on the fifth postoperative day after surgical placement of a ventricular peritoneal shunt for the correction of hydrocephalus. The nurse notes that the head circumference measurement has increased by 1 cm over the past 24 hours. The nurse analyzes this assessment data as which finding after this surgical procedure?1) Normal for this postoperative period 2) A complication related to the functioning of the shunt 3) Subcutaneous tissue swelling as a result of the surgical procedure 4) Insignificant and unrelated to the patency of the ventricular peritoneal shunt

ans: 2

2) A complication related to the functioning of the shunt The head circumference should decrease slightly every day as the superficial tissue fluid is reabsorbed after the surgical trauma. An increase in the head circumference indicates a lack of proper shunting of cerebrospinal fluid caused by either a blockage or a defect in the ventricular peritoneal shunt apparatus.Medical or surgical intervention is required. Options 1, 3, and 4 are incorrect interpretations.A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide?

1.Avoid prolonged exposure to the sun.

2.Adhere to a strict tyramine-restricted diet.

3.Recognize the signs and symptoms of a relapse of depression.

4.Have therapeutic blood levels drawn because the medication has a narrow therapeutic range.

ans: 1

1.Avoid prolonged exposure to the sun.photosensitivity is a side effect of antipsychotic medications. Maintaining a strict tyramine-restricted diet is applicable to monoamine oxidase inhibitors (MAOIs).Antipsychotics are not used to treat depression. Lithium is a mood stabilizer that requires monitoring of medication blood levels.