ATI RN Mental Health

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? a. The client is taking numerous deep, measured breaths b. The client is calmly telling their partner that "the staff here is so controlling" c. The client is sitting with their head in their hands and appears to be crying d. The client is pa...

a nurse is reinforcing teaching with a client who has type 2 diabetes mellitus and reports waking during the night with tremors and anxiety. which of the following information should the nurse include? - eat a bedtime snack a nurse is assisting with the admission of a client who has a latex allergy. the nurse should identify that which of the following supplied has the potential to contain latex? - indwelling urinary catheter a nurse is caring for a client who has an altered mental status ...

Primary survey - (A) Airway with cervical spine protection (restrict) (B) Breathing and ventilation (C) Circulation - stop the bleeding (D) Disability - neurological status (E) Exposure - undress and environment (temp control) REPEAT IF ANYTHING GOES WRONG Secondary survey - (A) Allergies (M) Medications (P) PMH and Pregnancies (L) Last meal (E) Environment and Events 3-3-2 Rule - 3 finger lengths between upper and lower incisors 3 finger lengths between hyoid and chin 2 finger ...

A nurse is assessing a client who is 4 hr postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect? A. Blood-tinged urine in the drainage bag B. Catheter tubing coiled at the client's side C. Client report of severe bladder spams D. Urinary output of 20 mL/hr - A. Blood-tinged urine in the drainage bag A nurse is caring for a client who is in the oliguric-anuric stage of acut...

The client is responsive and able to fully respond by opening their eyes and attending to a normal tone of voice and speech. What is the level of consciousness? - Alert The client is able to open their eyes and respond but is drowsy and falls asleep readily. What is the level of consciousness? - Lethargic The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. They might not be able to respond verbally. What is the level of con...

Check the client's electrolyte values - A nurse is caring for a client who is in the olgiuria-anuric stage of AKI. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? Calcium - A nurse is providing dietary teaching to a client who has late-stage CKD. Which of the following nutrients should the nurse instruct the client to increase in her diet? "You should not ejaculate for 24 hours prior...

A nurse is caring for a client who has chronic kidney disease (CKD) and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I just take the antacid magaldrate my husband has at home?" The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following? 1. Serum phosphorus levels 2. Serum potassium levels 3. Serum magnesium levels 4. Serum calcium levels - 1. Serum phosphorus levels A nurse...

A 55 year old male patient is diagnosed with chronic kidney disease. The patient's recent GFR was 25 mL/min. What stage of chronic kidney disease is this known as? A. Stage 1 B. Stage 3 C. Stage 4 D. Stage 5 - C. Stage 4 A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia - B. Anemia A 65 year old male patient has a glomerular filtration rate of 55 mL/min. The patient has a history of...

A nurse is planning care for a client who is postoperative following a nephrectomy. Which of the following assessments is the priority for the nurse to evaluate? A. Bowel sounds B. WBC count C. Pain level D. Blood pressure - D. Blood Pressure The greatest risk to the client is acute adrenal insufficiency. The adrenal gland can be removed or damaged during nephrectomy. The nurse should evaluate the client for hypotension, decreased urine output, and decreased level of consciousness. ...

A nurse is completing the admission assessment of a client who has renal calculi. Which of the following findings should the nurse expect? a. bradycardia b. diaphoresis c. nocturia d. bradypnea - B. diaphoresis A nurse is reviewing discharge instructions with a client who had spontaneous passage of calcium phosphate renal calculus. Which of the following instructions should the nurse include in the teaching? (select all that apply) a. limit intake of food high in animal protein b. r...