when palpating the clients neck for lymphadenopathy where should the nurse position himself
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. When palpating the client's neck for lymphadenopathy, where should the nurse position himself?

Correct answer: D

Rationale: When palpating the client's neck for lymphadenopathy, the nurse should position himself in front of a sitting client. This positioning allows for easier access to the neck area and better visualization of any swelling or abnormalities in the lymph nodes. Being in front of the client ensures proper alignment and comfort for both the nurse and the client during the assessment. Choices A, B, and C are incorrect because positioning at the client's back or sides would make it challenging to adequately palpate the neck area and assess for lymphadenopathy.

2. Which of the following statements does NOT apply to a nursing plan of care?

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

3. A client takes an antidepressant and oral contraceptives. Which herbal supplement should the nurse educate the client about as a potential drug-herb interaction?

Correct answer: D

Rationale: St. John’s Wort is the correct answer because it can interact with antidepressants and oral contraceptives, potentially affecting their efficacy. Iron supplement, garlic, and green tea do not typically interact with antidepressants or oral contraceptives to the same extent as St. John’s Wort.

4. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

Correct answer: A

Rationale: Choice A is the correct answer because repeating information and addressing the client’s questions as they arise is an effective method for reinforcing learning in adults. This approach allows for immediate clarification and reinforcement of important points. Choice B is incorrect because teaching all the information in one session may be overwhelming for the client and hinder retention. Choice C is incorrect as using a video with medical terms may not necessarily address the client's specific questions or concerns. Choice D is also incorrect because waiting for the client to ask questions may lead to missed opportunities for providing crucial information and addressing uncertainties.

5. Interacting with the patient and their family to obtain subjective information is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

Correct answer: D

Rationale: The correct answer is D, Assessment. Assessment in nursing involves obtaining subjective information from the patient and their family to gather data about the patient's health status. This step is crucial as it helps identify the patient's needs, strengths, and areas requiring intervention. Choice A, Evaluation, is incorrect as evaluation comes after the implementation of the care plan to determine its effectiveness. Choice B, Planning, is also incorrect as it involves developing a plan of care based on the assessment data. Choice C, Implementation, is the phase where the nursing interventions are carried out based on the established care plan.

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