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Ati pn comprehensive predictor 2023
Total Questions : 168
Showing 10 questions, Sign in for moreA nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?
1100:
History of alcohol use disorder. Family history of mood disorders.
1100:
The client is brought to an inpatient mental health facility by their partner after slipping on the kitchen floor while cooking breakfast. Client reports hitting their arm on the counter and reports pain as 6 on a scale of 0 to 10. A 4-inch laceration is noted on client's left arm. Client is not making eye contact with nurse and alcohol is detected on client's breath when speaking. Client has a flat affect, their hygiene is poor, and clothes are dirty. Client states they lost their job 6 months ago and does not feel that life is worth living if they are not earning a daily living.
1400:
The client reports feeling tired and is anxious. Left arm laceration sutured and pain medication administered. Client reports pain as 4 on a pain scale of 0 to 10.
A nurse is assisting with the care of a client.
Explanation
Rationale:
- Dependent personality disorder: Characterized by excessive need to be taken care of and fear of separation. This does not fit the client’s symptoms of hopelessness, poor hygiene, flat affect, and suicidal thoughts, which are more consistent with major depression.
- Schizophrenia: Involves hallucinations, delusions, and disorganized behavior, none of which are reported in this client. The absence of psychosis and the presence of mood-based symptoms suggest a depressive disorder rather than a psychotic disorder.
- Major depressive disorder: Fits with the client's expression of hopelessness, withdrawal, poor hygiene, job loss, and suicidal ideation. These are classic symptoms of major depression and require careful monitoring and support.
- Dementia: Typically includes memory impairment, disorientation, and decline in cognitive function. The client is coherent, oriented, and presenting with mood rather than cognitive issues, ruling out dementia.
- Speak with the client using simple words: While clear communication is always beneficial, there is no indication the client has cognitive impairment requiring simplified language. The priority is emotional support and safety, not communication complexity.
- Remain in the room with the client: Ensures the client feels supported and safe, especially in the context of suicidal ideation. Continuous presence also allows for immediate intervention if the client's mental state worsens.
- Encourage client to eat slowly: Not relevant to the client’s presentation. There are no issues with appetite, swallowing, or physical illness necessitating this intervention. It does not address the mental health concerns at hand.
- Assist the client to identify stressors: Helps promote insight and develop coping mechanisms. Identifying stressors is essential in managing depressive symptoms and planning appropriate therapeutic strategies.
- Determine client’s level of disorientation: The client is not exhibiting signs of confusion or disorientation. This action would be more appropriate for cognitive disorders such as dementia or delirium.
- Panic attacks: The client reports anxiety but has not described acute panic symptoms like hyperventilation or chest tightness. Monitoring panic attacks is not a priority in this depressive context.
- Hallucinations: There is no evidence of perceptual disturbances. The client is not demonstrating psychosis, so monitoring for hallucinations is not indicated.
- Wandering at night: More relevant for clients with dementia or delirium. This client is coherent and not at risk of nocturnal wandering.
- Suicidal ideation: A key concern due to the client expressing that life is not worth living. This must be monitored continuously for client safety and to guide suicide prevention strategies.
- Sleep patterns: Depression commonly affects sleep, leading to insomnia or hypersomnia. Monitoring sleep helps gauge treatment response and overall progress in managing depressive symptoms.
A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
A nurse is discussing risk factors for child maltreatment with a newly licensed nurse. Which of the following examples should the nurse include?
A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder, which of the following findings should the nurse expect 15 min following the procedure?
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?
A nurse is assisting in planning care for a 16-year-old client in a pediatric clinic. Which of the following actions would be a breach of confidentiality?
0800:
Parent states child was awake most of the night experiencing pain and is currently asleep. Heart rate regular without murmur. Respirations easy, shallow. Breath sounds clear throughout. Abdomen soft, tender in incisional area upon palpation. Absent bowel sounds. Right lower quadrant abdominal dressing dry and intact.
1200:
Child rates abdominal pain as 6 on FACES scale. Alert and irritable, cooperates with coaxing/playing. Child refuses use of incentive spirometer. Heart rate regular without murmur. Respirations easy, shallow. Breath sounds clear throughout. Abdomen soft, more tender upon palpation as compared to 0800. Bowel sounds hypoactive. Right lower quadrant abdominal dressing dry and intact.
1245:
Child rates abdominal pain as 4 on FACES scale.
1600:
Child rates abdominal pain as 3 on FACES scale. Heart rate regular without murmur. Respirations easy, shallow. Breath sounds slightly diminished in the bases. Child encouraged to use incentive spirometer, but child continues to decline use of the incentive spirometer. Abdomen with slight tenderness in the right lower quadrant. Bowel sounds hypoactive. Right lower quadrant abdominal dressing dry and intact.
0800:
- Temperature 37° C (98.6° F) temporal
- Heart rate 118/min
- Respiratory rate 20/min
- Blood pressure 92/52 mm Hg
- Weight 13,6 kg (30 lb)
1200:
- Temperature 37.2° C (99° F) temporal
- Heart rate 126/min
- Respiratory rate 22/min
1600:
- Temperature 37.7° C (99.9° F) temporal
- Heart rate 124/min
- Respiratory rate 24/min
1215:
Morphine sulfate 1 mg IV
Acetaminophen 120 mg rectally every 4 hr PRN for fever
Morphine sulfate 1 mg IV every 3 hr PRN for pain
A nurse on a pediatric unit is assisting with the care of a preschooler who is 1 day postoperative following an open appendectomy
Complete the following sentence by using the lists of options.
The preschooler is at greatest risk for developing
Explanation
Rationale:
- Pneumonia: The child’s shallow respirations, diminished breath sounds at the bases, and ongoing refusal to use the incentive spirometer suggest decreased lung expansion and poor airway clearance. These are classic risk factors for postoperative pneumonia, especially in pediatric clients who are reluctant to engage in deep breathing exercises.
- Peritonitis: Peritonitis would be indicated by signs such as a rigid abdomen, rebound tenderness, or marked fever. The client has mild abdominal tenderness but not the severity or systemic signs expected with peritonitis.
- Wound infection: There are no signs of wound infection. The surgical dressing is consistently described as dry and intact with no redness, drainage, or swelling, which are typical indicators of infection.
- Temperature: The child's temperature is slightly elevated but remains within the low-grade range and does not independently indicate a serious complication. It’s not the most significant factor in this case.
- Bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery and do not directly point to a respiratory complication. They are improving postoperatively and are not a primary concern for pneumonia.
- Breathing effort: The child’s consistently shallow respirations and diminished breath sounds show a risk for poor ventilation. These are warning signs for the development of postoperative pneumonia.
- Abdominal tenderness: Mild to moderate tenderness is expected 1 day after abdominal surgery and shows improvement over time. It is not strongly suggestive of a new or worsening condition like pneumonia.
- Refusal to use incentive spirometer: Using the incentive spirometer encourages deep breathing and lung expansion. Refusing it increases the risk of atelectasis and subsequent pneumonia, especially in pediatric clients with shallow breathing patterns.
- Surgical dressing: The dressing is consistently described as dry and intact with no signs of infection or complication. It does not point to any current or developing risk.
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