NURS 314 Health Assessment ATI COMPREHENSIVE MENTAL-1 LATEST UPDATED EXAM .

NURS 314 Health Assessment ATI COMPREHENSIVE MENTAL-1 LATEST UPDATED EXAM . 1. Following abdominal surgery, a client's abdominal wound edges are separating, and the wound is draining a large amount of serous drainage. Thenurse should place the client: Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further wound separation and tearing (dehiscence).Incorrect: This position is incorrect because it can increase tension on thesuture line, and cause further wound separation and tearing (dehiscence).Correct: The semi-Fowler's position decreases tension on the wound, and it may prevent further separation and tearing of the wound(dehiscence).Incorrect: This position is incorrect because it can increase tension on the suture line, and cause further wound separation and tearing (dehiscence). flat on the back with legs straight. in high-Fowler's position with legs straight. in semi-Fowler's position with the knees slightly bent. on the left side with knees bent . 2. The PN is preparing to administer an enteral feeding to a client. To prevent gastric cramping and discomfort due to the feeding, the nurse should: Correct: Cold formula can cause gastric discomfort. With enteral feedings, particularly via gastrostomy tube, the formula reaches the stomach quickly, with little or no opportunity to be warmed, as oral feedings would as they pass through the mouth and esophagus.Incorrect: Tube placement is confirmed prior to beginning each feeding. This action does not prevent gastric discomfort. However, checking tube placement does help prevent the infusion of the formula into the lungs.Incorrect: To prevent gastric discomfort, the concentration of the tube feeding formula needs to be advanced gradually. Full-strength formula may cause gastric discomfort, especially when the first few feedings areadministered.Incorrect: The head of the bed should be elevated at least 30° during the feeding and for at least 30 minutes after feeding. This is done to reduce the risk of aspiration, however, not to prevent cramping and discomfort. allow time for the formula to reach room temperature prior to administration. determine tube placement once every 24 hours. prepare to administer full-strength rather than diluted formula. elevate the head of the bed during and after feedings. 3. The nurse is caring for a child with cystic fibrosis (CF). Which intervention willhelp to prevent respiratory complications? Incorrect: Clients with CF should not receive cough suppressant syrups. These children need to cough frequently to clear lung secretions.Correct: Nebulization with mist or aerosol therapy followed by chest physiotherapyhelps to keep secretions free-flowing. The pulmonary effects of CF are progressive, and bronchial secretions must bekept moist.Incorrect: The child should change positions frequently to promote drainage from the lungs, and promote aeration of the lungs.Incorrect: Children with CF can safely receive the pertussis vaccine. These children need protection from pertussis because this infection causes severe respiratory complications. Encourage the use of cough suppressant syrup. Give frequent nebulization treatments. Limit changing the child's position to conserve the child's need for oxygen. Withhold the vaccine for pertussis. 4. The nurse is caring for a client following insertion of a pacemaker. The client isplaced on continuous ECG monitoring because it will: Incorrect: This is incorrect because pacemaker voltage settings are adjusted manually at the time of insertion.Incorrect: A chest x-ray is used to check the placement of pacer wires after a pacemaker insertion.Correct: The heart rate may change following pacemaker insertion because the pacemaker fails to maintain the pre-set heartrate. This problem can be detected immediately with continuous ECG monitoring.Incorrect: Fluoroscopy is used to determine dislodgement of pacer leads after a pacemaker insertion. Dislodgement can be prevented with bedrest andminimal arm and shoulder activity. allow the primary care provider to adjust voltage settings. check placement of the pacer wires. detect a dramatic change in heart rate. determine dislodgement of pacer leads. 5. The nurse is administering eye drops to a client. To prevent injury, the nurse should: Incorrect: The nurse should ask the client to "look up" before instilling the eye drops. This action reduces stimulation of the corneal reflex and injury to the eye, should the client jerk away.Incorrect: Eye drops should never bedropped directly onto the cornea as this action may injure the cornea. The nurse should deposit the medication onto the lower conjunctiva.Correct: As a safety precaution, the nurse administering eye drops should rest his hand on the client's forehead. In case the client moves, the nurse's hand will move at the same time, lowering the risk that thedropper will hit the client's eye.Incorrect: When administering eye drops, it is essential to have an adequate amount oflight. However, the nurse should not shine a bright light directly into the client's eye. ask the client to "look down" before instilling the eye drops. drop the eye drops directly onto the client's cornea. rest his hand on the client's forehead. shine a bright light into the client's eye. 6. Which statement is true regarding the behavior of clients who are in pain? Incorrect: Many clients avoid conversation and social contacts when they are experiencing pain. Clients with chronic pain may become withdrawn and isolated.Incorrect: Clients' reactions to pain are often influenced by theircultural and ethnic background. The nurse needs to consider each client's cultural background when assessing a client's pain.Incorrect: Clients often place their hands over the painful area as a self-protective or guardingmechanism to prevent further pain.Correct: Many clients fail to report or discuss their pain or discomfort with nursesand other caretakers. Thus, the PN needs to assess clients for pain on a routine basis. Clients experiencing pain may engage in social activities for distraction. Clients from different cultures react to pain in the same way. Clients in pain usually avoid touching the painful area. Clients who are in pain may not report their pain to the nurse or other caretakers. 7. A client is being discharged from same-day surgery following cataract extraction from the right eye. The nurse will instruct the client to: Correct: Lifting requires straining, which increases pressure in the eye and may disrupt suture lines.Incorrect: The client should not bend forward or lower the head. This action increases pressure in the eye and could disrupt suture lines.Incorrect: Mild pain is normal. However, moderate to severe pain should be reported to the surgeon.Incorrect: The client should sleep on the unaffected (left side) to reduce pressure in the eye. Increased pressure could disrupt the suture lines. avoid lifting anything heavier than five pounds until cleared by the surgeon. bend from the waist to pick up objects on the floor. call the surgeon immediately if he has any discomfort. sleep on his back or on his right side. 8. Substance abuse is diagnosed when the person's involvement with drugs oralcohol: Incorrect: Substance abuse is likely to cause or contribute to family conflict. However, family conflict is not a diagnostic criterion for substance abuse.Incorrect: Substance abuse usually leads to physical health problems overtime. However, physical illness is not a diagnostic criterion for substance abuse.Correct: A client has a problem with substance abuse when that person begins to develop interpersonal difficulties, and is not able to perform their roleadequately at work or at school.Incorrect: A person abusing substances may come to the attention of the law. However, the development of legal difficulties are not a diagnostic criterion for substance abuse. causes family conflicts. causes physical illness. interferes with the person's ability to function. results in legal problems. 9. A newly employed nurse discovers that some medication doses are incorrect. Coworkers admit that changes in medication orders have not been processedcorrectly, but they advise the nurse to administer the medication anyway. The nurse should: Incorrect: This action is an unsafe practice, and it violates the five rights of medication administration.Incorrect: Reporting the incident to the State Board of Nursing is not the first step in resolving theissue.Correct: The nurse needs to inform the nurse manager about the unsafe medication practice and incorrect medication dosages. The nurse manager can then determine how to resolve this intradepartmental issue.Incorrect: Resigning will not resolve the issue and it will allow the unsafe practice to continue. give the dose that is available. report the incident with documentation to the State Board of Nursing. report this unsafe practice to the nurse manager. resign due to unsafe practices. 10. The nurse is teaching a client with tuberculosis about ways to reduce spreadof the disease to others. Teaching is effective when the client states: Incorrect: Tuberculosis is spread by droplet nuclei, and not through contact with the skin of an infected person.Incorrect: Tuberculosis is spread by droplet nuclei, and not through blood contact.Incorrect: Clients with tuberculosis need to cover their mouths when they laugh to reduce spread of the disease.Correct: Tuberculosis is spread by droplet nuclei. Thus, covering the mouth when coughing decreases the release of droplet nuclei into the air, and the spread of the disease to other people. "I can transmit tuberculosis to others by touching them." "I can transmit tuberculosis to others through contact with my blood." "I don't need to cover my mouth when I laugh." "I'll cover my mouth with a tissue when I cough." 11. The nurse performs a physical assessment on a newborn baby. Which finding, if noted, is abnormal and needs to be reported? Incorrect: Apnea lasting 5-15 seconds is periodic apnea, and is normal for the newborn. No intervention is required as long as there is no change in the infant's heart rate.Incorrect: A blue color in the fingers and toes is called acrocyanosis, and it is a normal finding in the newborn in the first couple of days after birth.Incorrect: Gagging orchoking is common in the hours following birth because the infant was in a fluid-filled environment for the gestation. There should be a bulb syringe in the infant's crib at all times to suction the mouth, pharynx, and nose, and clear theairway as needed.Correct: Normal respirations range for the newborn is 30-60 respirations per minute. Rapidbreathing is a sign of respiratory distress, which may indicate sepsis or other complications and should be reportedimmediately. Apnea lasting 5 to 15 seconds Blue color in the fingers and toes Gagging or choking Respirations of 80 per minute 12. The nurse is providing discharge teaching to a client who is at high risk forinfection. The client asks if there is any way to prevent getting a cold. Whichresponse from the nurse is correct? Incorrect: The common cold is caused by a virus. Antibiotics are not prescribed for the common cold.Incorrect: This is not practical advice, and it does not necessarily eliminate exposure.Incorrect: A mask may decrease risk of infection, but it is not the most effective measure.Correct: Handwashing is the most effective preventive measure for a cold. "Ask your doctor for an antibiotic that you can take." "Stay indoors during the height of cold and flu season." "Wear a mask when going outdoors during cold and flu season." "Wash your hands frequently during cold and flu season." .