ATI LPN
ATI PN Adult Medical Surgical 2019
1. The nurse is caring for a client who is receiving chemotherapy. Which laboratory result indicates that the client is at risk for infection?
- A. Hemoglobin level of 12 g/dL.
- B. Platelet count of 150,000/mm3.
- C. White blood cell count of 2,000/mm3.
- D. Serum creatinine level of 1.0 mg/dL.
Correct answer: C
Rationale: A white blood cell count of 2,000/mm3 is low and indicates leukopenia, which increases the client's risk for infection. Hemoglobin level and platelet count are not directly indicative of infection risk. Serum creatinine level is related to kidney function, not infection risk.
2. A client with pancreatitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fat foods.
- B. I should decrease my intake of high-fat foods.
- C. I should increase my intake of high-protein foods.
- D. I should decrease my intake of high-protein foods.
Correct answer: B
Rationale: The correct answer is B. Decreasing the intake of high-fat foods is essential in managing pancreatitis as high-fat foods can exacerbate symptoms and lead to complications. By reducing high-fat foods in their diet, the client demonstrates an understanding of the dietary management needed for pancreatitis. Choices A, C, and D are incorrect. Increasing high-fat foods (Choice A) is not recommended for pancreatitis as it can worsen the condition. While high-protein foods (Choice C) can be beneficial in some cases, the primary focus in pancreatitis management is on reducing fat intake. Decreasing high-protein foods (Choice D) is not a key dietary management approach for pancreatitis.
3. An 81-year-old female client has presented to the emergency department accompanied by her daughter with whom she lives. The daughter states that her mother has experienced a recent series of falls, which have resulted in her facial and arm bruises. The client smells of urine and is noticeably emaciated, unkempt, and anxious while the daughter berates her during the nurse's assessment. What is the nurse's responsibility in this situation?
- A. Determine the daughter's legal status with regard to her mother's financial affairs
- B. Report suspected elder abuse
- C. Establish whether the client has a durable power of attorney in place
- D. Obtain medical records regarding prior admissions for similar problems
Correct answer: B
Rationale: In cases of suspected elder abuse, the nurse is responsible for reporting his or her suspicions to the relevant authorities. In this scenario, the signs of elder abuse are evident, such as the client's bruises, unkempt appearance, and the daughter's behavior. Determining the daughter's legal status or the client's power of attorney are not immediate priorities when abuse is suspected. Obtaining medical records for prior admissions is also not the primary concern in this situation.
4. What is the primary goal of eye movement desensitization and reprocessing (EMDR) when treating a patient with posttraumatic stress disorder (PTSD)?
- A. To help the patient confront and process traumatic memories
- B. To help the patient change negative thought patterns
- C. To help the patient develop relaxation techniques
- D. To help the patient avoid triggers
Correct answer: A
Rationale: The primary goal of eye movement desensitization and reprocessing (EMDR) in treating patients with posttraumatic stress disorder (PTSD) is to help them confront and process traumatic memories. EMDR uses bilateral stimulation to facilitate the processing of distressing memories, leading to their desensitization and reprocessing, ultimately reducing PTSD symptoms.
5. Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?
- A. Serum albumin level of 3 g/dL
- B. Braden scale score of 20
- C. Norton scale score of 18
- D. Hemoglobin level of 13 g/dL
Correct answer: A
Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.
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