the hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs the nurse teaches the mother that the preferred way t
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 1

1. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:

Correct answer: A

Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.

2. Which of the following is a process of heat loss that involves the transfer of heat from one surface to another?

Correct answer: B

Rationale: Conduction is the process of heat transfer that occurs between objects or substances that are in direct contact with each other. In this process, heat is transferred from a hotter surface to a cooler surface through direct contact. This type of heat transfer does not involve the movement of the substances themselves, only the transfer of thermal energy. Radiation (Choice A) is the transfer of heat through electromagnetic waves, while convection (Choice C) is the transfer of heat through the movement of fluids. Evaporation (Choice D) is a cooling process that involves the phase change of a liquid into a gas.

3. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

Correct answer: D

Rationale: The correct choices are B and C. Assessing grasp strength and orientation to person, place, and time are essential components of a neurological assessment after a CVA. Pulse assessment in all four extremities is more relevant to circulatory assessment rather than neurological status. Therefore, option A is incorrect.

4. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this scenario. Cellulitis is a bacterial skin infection that requires prompt treatment with antibiotics to prevent its spread and potential complications. While warm moist packs and elevation can be beneficial as adjunct measures, they are not the initial priority. Teaching about skin and foot care is important, but it can be addressed after stabilizing the acute condition with antibiotics.

5. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

Similar Questions

Which of the following is a specialized medical treatment and teaching facility that provides general and specialized medical and dental care and treatment?
A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client?
The nurse is planning to provide education about foods containing thiamine to a group of clients. Which food high in thiamine should the nurse include?
The client is complaining of painful swallowing secondary to mouth ulcers. Which statement by the client indicates appropriate management?
The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes?

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