A nurse is caring for a client who had abdominal surger y 24 hours ago. Which of the following actions is
the priority? A. Assess fluid intake every 24 hours B. Ambulate three times a day C. Assist with deep
breathing and coughing D. Monitor the incision site for findings of infection C The priority action the
nurse should take when using the airway, breathing, circulation approach to client care is to assist the
client with deep breathing and coughing, which reduces the risk for postoperative pneumonia. A nurse is
talking with a client who hasstage IV breast cancer. The nurse should recognize which of the following
statements by the client as a constructive use of a defense mechanism? A. I have experienced physical
discomfort when intimate with my partnersince my diagnosis B. I wish other women would stop
socializing with my partner C. I told my doctor that I would like to start a support group for other women
who are sick in my community D. I used to mistrust my doctor, but now I know that she is the best one
to care for me during my illness C Thisstatement indicates that the client is using the constructive
defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she
does not wish to accept. A nurse is caring for a client who has immunosuppression and a continuous IV
infusion. Which of the following actions should the nurse take? A. Assess the clients IV site every 8 hours
B. Check the clients WBC count every 48 hours C. Monitor the clients mouth every 8 hours D. Change
the clients IV tubing every 48 hours C A nurse is caring for a 2-month-old infant who has Hirschsprung
disease (HD). Which of the following areas should the nurse assess for manifestations of HD? A. Eyes
area B. Chest area C. Lower abdominal area RN ATI Capstone Proctored Comprehensive Assessment
with 100% verified solutions-2026-2027 C Hirschsprung disease is a condition that affects the large
intestine (colon) and causes problems with passing stool. This is present at birth (congenital) as a result
of missing nerve cellsin the muscle of the baby's colon A nurse at a mental health clinic is caring for four
clients. The nurse should recognize that which of the following clients is using dissociation as a defense
mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement B. A client who
was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter
than average is verbally assertive with coworkers D. A client states that they did not get a job promotion
because the boss did not like them B A nurse is providing teaching to a client who has a new diagnosis of
type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following
findings as a manifestation of hypoglycemia? A. irritability B. increased urination C. vomiting D. facial
flushing A A nurse in an outpatient mental health clinic is caring for four clients. The nurse should
recognize that which of the following clients is effectively using sublimation as a defense mechanism? A.
A client who transfers their anger about their job onto their family and then apologizes B. A client who
misses provider appointments because they say they are too busy C. A client who channels their energy
into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place
for him at dinner each night C The nurse should identify that this client is using the defense mechanism
of sublimation by channeling negative feelings over the loss of their job into a new hobby. A hospice
nurse is consulting with a client and her family about receiving home services. Which of the following
statements should the nurse identify as an indication that the family understands home hospice care? A.
"We can expect the hospice nurse to provide support for us after our mother's death." RN ATI Capstone
Proctored Comprehensive Assessment with 100% verified solutions-2026-2027 B. A hospice nurse will
come to the house each time our mother needs pain medication C. Now that my mother is receiving
hospice services, we will not be able to get respite care D. Hospice care focuses on arranging treatment