level 3 practice a/t/i Exam Questions And Answers

level 3 practice a/t/i Exam Questions And Answers A nurse is caring for an older adult client who has kidney failure. The client tells the nurse that she has decided to stop hemodialysis treatment. Which of the following actions by the nurse is appropriate in regard to serving as the client's advocate? - ANS Supporting the client's decision regarding treatment -The nurse's role as client advocate is to support the client's decision to discontinue treatment. A nurse is caring for an older adult client. The client received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribed. Which of the following entries is the appropriate documentation of this occurrence in the client's medical record? - ANS 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable.- The nurse should document the amount of fluid, how long it took to infuse, and the client's physical status. When planning care for a child who has increased intracranial pressure (ICP), which of the following should the nurse include in the child's plan of care? - ANS Maintain head in midline. -The child's head should be maintained in a midline position to promote venous return and prevent an increase in ICP. - ANS Sleepy/Widening pulse pressure//decerebrate posturing..... Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP.// Widening pulse pressure is correct. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP.// Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP. A nurse is talking with a client who is beginning chemotherapy. She tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first? - ANS Discuss the importance of hair with the client.--The first action the nurse should take using the nursing process is to assess the client. By identifying the importance of hair to the client, the nurse can acknowledge the importance of the expected loss to the client and assist the client with anticipatory grieving. - ANS an inability to manage finances.-- Clients who are in stage 4 have difficulty with tasks that require planning and math skills, such as managing finances. - ANS Fine and gross motor skill challenges- Fine and gross motor skill challenges are manifestations of spastic cerebral palsy.