a nurse is caring for a client who is at risk for pressure ulcers which of the following interventions should the nurse implement a nurse is caring for a client who is at risk for pressure ulcers which of the following interventions should the nurse implement
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ATI Exit Exam 2023 Quizlet

1. A nurse is caring for a client who is at risk for pressure ulcers. Which of the following interventions should the nurse implement?

Correct answer: A

Rationale: The correct intervention for preventing pressure ulcers in a client at risk is to turn the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and preventing tissue damage. Using a donut-shaped cushion can actually increase pressure on the skin and worsen the risk of pressure ulcers. Elevating the head of the bed to 45 degrees is beneficial for preventing aspiration in some cases but does not directly address pressure ulcer prevention. Massaging reddened areas can further damage the skin and increase the risk of pressure ulcer development by causing friction and shearing forces.

2. The client is on enoxaparin (Lovenox) for DVT prophylaxis. What is the most important lab value to monitor?

Correct answer: A

Rationale: The correct answer is A: Platelet count. When a client is on enoxaparin (Lovenox), monitoring the platelet count is crucial as enoxaparin can lead to a rare but serious side effect known as heparin-induced thrombocytopenia (HIT), causing a decrease in platelet count. Monitoring the platelet count helps detect this adverse reaction early. Choices B, C, and D are incorrect because enoxaparin therapy does not directly affect PT/INR, aPTT, or hemoglobin levels.

3. A nursing student asks what essential hypertension is. What response by the registered nurse is best?

Correct answer: C

Rationale: Essential hypertension, also known as primary or idiopathic hypertension, is the most common type of hypertension. It has no specific underlying cause such as an associated disease process. In contrast, hypertension that is due to another disease is referred to as secondary hypertension. Malignant hypertension is a severe and life-threatening form of hypertension characterized by rapidly progressive blood pressure elevation and potential end-organ damage.

4. Alison believes that individuals learn to be either aggressive or nonaggressive as a result of the experiences they have. Alison's views are most consistent with which view in psychology?

Correct answer: A

Rationale: Alison's belief that individuals learn to be either aggressive or nonaggressive as a result of their experiences aligns with the Behaviorist view of psychology. Behaviorism focuses on how behavior is learned through interactions with the environment, emphasizing the role of experience in shaping behavior. The other options are not directly related to the idea that behavior is learned through experiences: Structuralism focuses on the structure of conscious experience, Functionalism emphasizes the purpose of behavior, and Psychoanalytic theory focuses on the role of unconscious processes.

5. What information should the nurse include when teaching an adolescent with Crohn disease (CD)?

Correct answer: A

Rationale: Teaching about coping with stress and adjusting to chronic illness is crucial for adolescents with Crohn disease. CD is a chronic condition with no cure, so focusing on managing the disease, stress, and diet is essential for improving the adolescent's quality of life. Choice B is incorrect because Crohn disease cannot be cured surgically. Choice C is relevant but not as essential as coping with stress and chronic illness. Choice D is not a priority in teaching an adolescent with Crohn disease as it mainly focuses on preventing the spread of illness to others, which is not a significant concern with CD, and high-fiber diets may not always be suitable for individuals with this condition.

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