ATI Adult Health lll Exam 4 Answers

ATI Adult Health lll Exam 4 Answers 1. The nurse on the neurological unit is positioning a client who had a stroke two days ago and had left-sided hemiparesis. Which of the following actions by the nurse would be appropriate? Select all that apply. a. Positioning a rolled washcloth in the client’s left hand b. Placing a foam abduction wedge between the client’s legs c. Grasping the client’s left arm to pull the client from supine to a right side-lying position d. Securing the left arm in a sling e. Putting a trochanter roll on the outside of the client’s left hip when the client is supine. 2. The nurse is caring for a client who has expressive aphasia following a stroke. The nurse has taught the client’s spouse about ways to facilitate communication. Which of the following comments by the client’s spouse would require follow-up? a. “I wait after I ask my spouse a question, to give as much time as needed to answer.” b. “I ask my spouse questions like, ‘Do you like this movie?’ instead of ‘What do you think of this movie?’” c. “I act like I understand when I do not, so that my spouse will not become frustrated.” d. “I tell my spouse, ‘Point to what you want” so I do not get frustrated trying to understand.” 3. The nurse is caring for a client with increased intracranial pressure (ICP) who has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following prescribed interventions should the nurse implement? a. Electrolyte restriction b. Electrolyte replacement c. Fluid replacement d. Fluid restriction 4. The nurse is planning care for a client who has a recent diagnosis of multiple sclerosis (MS). Which of the following interventions should the nurse include in the client’s care plan? a. Instruct the client on daily muscle stretching exercises b. Provide total assistance with all activities of daily living (ADLs) c. Encourage the client to follow a low-residue diet d. Encourage client to void every hour 5. The nurse is caring for a group of assigned clients. Which of the following client’s should the nurse see first? a. The client with ulcerative colitis who reports left lower quadrant abdominal pain and passing stools that appear bloody with mucus and pus. b. The client with breast cancer receiving prescribed chemotherapy whose platelet count is 52,000/uL and reports having shaking chills. c. The client with hepatitis B virus who was admitted with jaundice and now has changes in cognitive function. d. The client recovering from an ischemic stroke who has decreased lung sounds, productive cough and a temperature of 104.8 F. 6. The nurse is planning an education conference about anticoagulation and the direct factor Xa inhibitor medications. Select all that apply. a. Aspirin b. Coumadin c. Dipyridamole d. Rivaroxaban e. Apixaban 7. The nurse in an outpatient setting is assessing a client’s risk for ischemic stroke. The nurse should assess for which of the following conditions? Select all that apply. a. Atrial fibrillation b. Hemophilia c. Diabetes Mellitus d. Epilepsy e. Concussion f. Carotid Stenosis 8. The nurse is caring for a client with a traumatic brain injury (TBI) following a fall. Which of the following medications should the nurse anticipate being prescribed for the client to reduce cerebral edema? a. Mannitol