Nursing Care Priorities and Interventions | Exams Biology | Docsity (2024)

Download Nursing Care Priorities and Interventions and more Exams Biology in PDF only on Docsity! NSG 4060 Comprehensive ATI Practice B-Questions with Verified Answers Guaranteed Success A nurse is assessing a client who received 2 units of packed RBCs 48 hrs. ago. Which of the following findings should indicate to the nurse that the therapy has been effective? Hemoglobin 14.9 g/ld. The nurse should identify that packed RBCs are administered to clients who have a decreased level of hemoglobin or hematocrit. This h hemoglobin level is within the expected reference range of 14 to 18 g/ld. for males and 12 to 16 g/ld. for females, indicating the therapy have been effective. A nurse working in an n emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A middle adult client who has unstable vital signs. Using the stable vs. unstable approach to client care, the nurse should recommend priority treatment for the client who has u notable vital signs because this client requires immediate treatment to reduce the risk of further injury or possible death. A nurse is caring for a c lien that has fluid volume overload. Which of the following tasks should the nurse delegate to the CNA? Measure the client’s daily weight It is within the CNAs range of function to measure a client’s daily weight, so the nurse should delegate this task to them. A nurse is preparing to administer manifold 0.2g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse should administer? 18 g A nurse is conduction a physical examination for an adolescent and is assessing the range of motion of the legs. W hitch of the following images indicates the adolescent is abducting the hip joint? In the correct image, the adolescent is abduction the hip joint by moving the leg away from the midline of the body. A nurse is caring for a c lien that has hyperthyroidism. Which of the following findings should the nurse expect? Tremors Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia. A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following findings should the n ruse expect? Nuchal rigidity This is a manifestation of bacterial meningitis. A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take? Auscultate the apical pulse at least 1 min. The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds. The ileostomy pouch should be emptied when it is one-third to one-half full to prevent stool leakage and skin irritation. A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 yr. ago. Which of the following lab values should the nurse report to the provider? Sodium 148 mEq/L The nurse should report this sodium level because it is a bore the expected reference range of 136 to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease often retain sodium and require sodium-restricted diets. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to a CNA? Arrange the lunch tray for a client who has a hip fracture. Assisting a client with meals is within the range of function of the CNA. A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? Instruct the client to void. The nurse should instruct the client to void prior to the procedure because an empty bladder decreases the risk of a bladder puncture and minimizes the client’s discomfort during the procedure. A nurse has received change of shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction? A client who is receiving an MAOI and is requesting a cheeseburger for dinner. This client’s food selection contains tyrosine. Clients prescribed an MAOI must restrict the intake of foods that contain tyrosine due to adverse effects, such as hypertension. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. W hitch of the following actions should the nurse plan to take? Allow for frequent rest periods throughout the day. The nurse should encourage the client to balance rest with exercise to maintain muscle strength, joint function, and range of motion. A nurse is caring for a c lien who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased u urinary output. Which of the following action should the nurse take? Irrigate the catheter with 0.9% sodium chloride irrigation. Decreased urine output and bladder spasms indicate internal obstruction of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does n to clear. A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? PH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35-7.45. A pH level of less than 7.35 indicates acidosis. For a client who has COPD, a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45 mm Hg, indicating respiratory acidosis. A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Abdominal bloating The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. A nurse is caring for a c lien that has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease? Have the client wear a surgical mask while being transported outside the room. This will prevent the transmission of the disease. A nurse is caring for a g group of clients. Which of the following clients should the nurse attend to first? An older adult client who is anxious and attempting to pull out an IV line. This client is at greater risk of injury. An RN is observing an LPN and a CNA move a client up in bed. For which of the following situations should the nurse intervene? The LPN and the CNA grasp the client under his arms to lift him up in bed. They should not grasp the client under the arms when lifting, as this can result in shoulder dislocation or other injuries to the client. The RN should intervene and instruct the nurses to use a draw sheet or friction-reducing device to lift the client. A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take? Hold the insulin pen device perpendicular to the client’s skin to inject the medication. This ensures the insulin enters the sub tissue. A nurse is caring for a c lien that has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? The nurse should verify that the pH l evil of the client’s gastric aspirate is less than 5 to determine proper placement. An antepartum nurse i s caring for four clients. For which of the following clients should the nurse initiate seizure precautions? A client who is at 33 weeks gestation and has severe gestational hypertension. The nurse should initiate seizure precautions for a client who has severe gestational because extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client’s reach. A nurse is providing d is charge teaching to a client who is to receive home oxygen therapy. Which of the following i instructions should the nurse include in the teaching? Wear clothing made with cotton fabrics while oxygen is in use. Woolen and synthetic fabrics can generate static e electricity, which increases the risk of a fire. A nurse is providing t reaching for a client who has a fracture of the right fibula with a short-leg cast in place and a n we prescription for c retches. The client is non-weight bearing for 6 weeks. Which of the following i instructions should the nurse include in the teaching? Use the three-point gain. This allows the client to be mobile without bearing weight on the affected extremity. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the n ruse include in the change-of-shift report? The time of the client’s last dose of pain medication. The nurse should recognize than an effective handoff report provides a baseline of the client’s status for comparison and should include any recent changes or priority situations affecting the client’s condition. The time of the client’s last dose of pain meds is important to include so the receiving nurse can anticipate what time to give the next dose. A nurse is assessing a n infant who has hydrocephalus and is 6 hr postop following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider? Irritability when being held. This is a manifestation of increased intracranial pressure, which is an indication that the VP shunt is malfunctioning. This finding should be reported to the provider immediately. A nurse is caring for a c lien that has a prescription for chlorpromazine. Which of the following finding should the n ruse identify as an indication that the medication is effective? Decreased hallucinations. This is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia. A nurse is providing t reaching about lithium to a client who has bipolar disorder. Which of the following statements s hold the nurse include in the teaching? “Notify your provider if you experience increased thirst” Increased thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider. A nurse caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? Insert a lubricated gloved finger and advance along the rectal wall. This is the correct way of doing this. A nurse is planning to delegate client care tasks to a CNA. Which of the following tasks should the nurse plan to delegate to the CNA? Perform gastrostomy feedings through a client’s established gastrostomy tube. This task is within their range of function. A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? Delegate non-nursing tasks to ancillary staff. It is an effective method of providing high-quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks. A nurse on an inpatient m entail health unit is monitoring a visit between a client who has a history of aggressive b behavior and the client’s partner. Which of the following should the nurse identify as an indication of potential violence? The client is pacing around the chair in which their partner is sitting. Hyperactivity and pacing indicate that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences. A nurse is caring for a c lien who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, “I’m not sure about this now. I’m afraid it’s too risky.” Which of the following responses s hold the nurse make? “You have the right to change your mind about this p procedure at any time.” The client can refuse to consent at any time for a procedure. The nurse is demonstrating advocacy by respecting the client’s wishes r regarding care. A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services d ate for this minority group, the nurse should gather information from which of the following sources? Agency for Healthcare Research and Quality A nurse is providing t reaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should i instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? Irritability The nurse should instruct the client to monitor for irritability, which can indicate decreased blood glucose levels. A nurse is providing t reaching to a client who is scheduled for ECT. The nurse should inform the client that which of the following is an adverse effect of ECT? Short-term memory loss This is a common adverse effect of ECT. A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for a break. Which of the following statements should the charge nurse make to address this conflict? “I would like to talk to you about the unit policies r regarding break time.” The charge nurse is dealing with the conflict i n a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront. A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and v omitting for the past 2 days. Which of the following findings should the nurse expect? Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting. A nurse is caring for an o older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients a deed to the feeding? Albumin 2.8 g/ld. The nurse should recognize that an albumin level of less than 3.5 g/ld. indicates malnutrition and a need for additional nutritional supplementation. The expected reference range for albumin is 3.5 to 5 g/LD. A nurse is conducting g group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? “I told my doctor that I would like to start a support group for other women who are sick in my community.” This statement indicates that the client is demonstrating altruism by reaching out and helping others. A nurse is providing d dietary teaching to a client who has a new prescription for phenelzine. Which of the following f good recommendations should the nurse make? Broccoli, yogurt, cream cheese Clients taking an MAOI should not eat foods that contain tyrosine. Fermented meat such as pepperoni and bologna are high in tyrosine. A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? Edema Compartment syndrome causes increased pain, pallor, a ND Paresthesia from increased edema in the compartment involved. A nurse is providing d is charge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse’s priority? Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs. risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following r exports by the client should indicate to the nurse that the client has a detached retina? Floating dark spots These are a manifestation of a detached retina due to bulges, folds, or holes in the affected retina. A nurse on a med-surge u nit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? Difficulty performing ADLs A referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, and eating. A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? Rapid decrease in blood pressure this is an indication of hemorrhage. A nurse is caring for a c lien who recently signed an informed consent form to donate a kidney to her sibling who had end-stage kidney d disease. The donor states to the nurse, “I don’t want my brother to die, but what if I need this kidney one day?” Which of the following responses should the nurse make? Make a referral for social services As a client advocate, the nurse should support the client’s decisions and obtain a referral for social services to ensure that the client’s needs a t home are met. Social services can set up home care or hospice care services for the client i if needed. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? Occlusive dressing on the insertion site. This prevents air from leaking and is an expected finding. A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client’s family tells the n ruse they are concerned about the level of care the client will receive. Which of the following a actions should the nurse take? Facilitate an interdisciplinary conference at the new facility for the family. This will address the family’s concerns about providing optimal care for the client. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following s hold the nurse identify as an adverse effect of the medication? Blurred vision This is an adverse effect of amitriptyline and the provider should be notified. A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? “A client who requires airborne precautions should be placed in a negative-pressure airflow room.” Airborne precautions require a negative-pressure airflow room that has at least 6-12 air exchanges each hour using a HEPA filtration system. A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? Verify the client and blood product information with another licensed nurse. The nurse should compare the blood product label against the medical record and the client’s identification number with another nurse to ensure the correct blood product is administered to the correct client. A nurse in a mental h earth clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their f forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation. A nurse is caring for a c lien that has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? Apply a cold pack to the client’s ankle for 30 min/hr The nurse should clarify a prescription for a cold pack to the client’s ankle because type 1 diabetes mellitus is a contradiction for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation. A nurse is teaching about adverse effects with a client who s is starting to take captopril. Which of the following findings should the nurse identify a s an adverse effect of the medication to report to the provider? Cough This is due to the buildup of bradykinin in the lungs. The client should report this to the provider. A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg. and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? Respiratory acidosis A client who has respiratory acidosis will have decreased pH below the expected reference range of 7.35-7.45, an increased PaCO2 above the expected reference range of 35-45 mm Hg, and an HCO3 within the expected reference range of 22-26 mEq/L. A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile i idiopathic arthritis. Which of the following questions should the nurse ask to assess for an a diverse effect of this med? “Have you had any stomach pain or bloody stools?” These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen. A nurse in a pediatric unit has received a change-of-shift report for four children. Which of the following children should the nurse assess first? A 10-year-old child who is awaiting surgery f or an appendectomy and experienced sudden relief from pain. Using the urgent vs. noncurrent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an i indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately. According to evidence-based practice, p lining is the most important step in managing time effectively. The nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities. A nurse is caring for a c lien that has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning lab values for the client are apt 98 seconds and INR 1.8. Which of the following actions should the nurse take? Withhold the heparin infusion. The expected value for apt is 40 seconds. A therapeutic level of heparin increases the apt by a factor of 1.5-2, making the apt 60-80 seconds. An apt level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld until the apt returns to the therapeutic range. A nurse is providing t reaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. W hitch of the following instructions should the nurse include? Take the medication 15 mines before playing sports. Take 5-20 min prior to exercise to promote bronchodilating. The meds effects begin immediately, peak in 30-60 min, and can last for up to 5 hr. A home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse should initiate a request for a h high-frequency chest compression vest in response to which of the following parent statements? “My child has only a small amount of mucus after percussion therapy.” The nurse should recommend a high-frequency chest compression vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration. A nurse is planning care for a patient who is receiving chemotherapy and has neutropenia. Which of the following i interventions should the nurse include in the plan? Avoid including raw fruits in the client’s diet. This reduces the risk of bacterial infections. A nurse is caring for a c lien that is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. W hitch of the following assessments is the nurse’s priority? Amount of vagin*l bleeding. The first action the nurse should take u sing the nursing process is assessing the amount of vagin*l bleeding. A client who is in the f fourth stage of labor is at risk for hemorrhage, so assessing the amount of vagin*l bleeding is the nurse’s priority. A nurse is caring for a c lien that is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect? Hypernatremia The nurse should expect a decrease i n sodium levels because sodium is drawn to the edematous burn areas and lost through plasma leakage. A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? “I will need to measure your weight daily.” The nurse should instruct the client that daily w eight measurement is a necessary part of administering nutrition through a central l in to avoid fluid overload and monitor for adequate weight gain. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client u sing? Flight of ideas. Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes. A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? A client whose caregiver requests adult daycare services. The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services. A nurse at a mental h earth clinic is caring for four clients. The nurse should recognize that which of the following clients i s using dissociation as a defense mechanism? A client who was abused as a child describes the abuse as if it happened to someone else. The nurse should identify that this client i s using the defense mechanism of dissociation because they are separating painful events from the conscious mind and describing the events as if they happened to another person. A nurse is caring for a c lien that has active pulmonary tuberculosis. Which of the following actions should the nurse take? Assign the client to a private room with negative air pressure. To control the spread of active TB, the nurse should assign the client to a private room with negative air pressure. A nurse is providing t reaching to a client who is at 24 weeks of gestation and is scheduled for a 3 hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? “You will need to fast the night before the test.” The nurse should instruct the client that they will need to fast the night before the test to prevent inaccurate test results. A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood level of 3 mcg/ld. Which of the following actions should the nurse take? Recommend rescreening in 1 year. This level is within the expected reference range. A nurse is caring for a c lien that has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make? “Tell me more about your understanding of the options.” This is therapeutic because it is offering a general lead that facilitates communication between the nurse and the client and will help the nurse to explore the client’s feelings about the treatment options. A nurse is caring for a c lien that has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this med? Dry mouth. Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and ADD. The nurse should inform the client that dry m out, or xerostomia, is a common adverse effect of this med. A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following i interventions should the nurse include in the plan? Support the client’s left arm on a pillow while sitting. This prevents the extremity from hanging freely because this can cause shoulder subluxation. A nurse is caring for a c lien that has acute blood loss following a trauma. The client refuses a blood transfusion that m night potentially save their life. Which of the following actions should the nurse take first? Explore the client’s reasons for refusing the treatment. This is assessment. The nurse should gather more data regarding the client’s decision to refuse the blood transfusion. A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. Inspection, auscultation, percussion, palpation Inspect to assess skin integrity and symmetry. Auscultate. Percuss for tympani, dullness, absence or flatness of resonance. P palpate for tenderness, pain, or the presence of a mass. A nurse is providing t reaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? “I will not allow anyone to smoke near my baby.” Research indicates a strong correlation between exposure to cigarette smoke and the occurrence of SIDS. A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic t technique? Maintain sterile objects with the line of vision. Objects out of the line of vision are not considered sterile. Keep sterile items at least 1 inch (2.5cm) away from the border of a sterile drape. Hold gloved hands away from the body and above waist level to prevent contamination. A nurse is caring for a c lien that has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? Initiate continuous cardiac monitoring. This client is at risk for cardiac dysrhythmias a ND cardiac arrest. A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following f endings indicates the client’s use of ginger tea is effective? The client reports a decrease in episodes of nausea. The client can also use ginger ale and ginger snaps to alleviate nausea associated with pregnancy. A nurse is caring for a c lien that has a deep vein thrombosis. Which of the following actions should the nurse take? Instruct the client to elevate the affected extremity when sitting. Reduce edema and facilitate venous r return. A nurse is preparing to replace a client’s transdermal fentanyl patch after 72 hours of use. After the nurse opens the packet containing the new patch, the client declines to accept it. Which of the following actions should the nurse take? Ask another nurse to witness the disposal of the new patch. Place the med in a secure receptacle, according to agency policy, when disposing of any unused portion of a controlled substance. A nurse is assessing a n older adult client who has pneumonia. Which of the following findings should the nurse expect? Acute confusion. Will have acute confusion, fatigue, lethargy, and anorexia. A nurse is providing c lien teaching about the basal body temp method of birth control. Which of the following information should the nurse include in the teaching? “Your body temp might decrease slightly just prior to ovulation.” A client who is postoperative with abdominal distention and no bowel sounds. Using the acute vs. chronic approach to client care, the nurse should first assess the client who is postoperative with abdominal distention and no bowel sounds because these manifestations are an indication of paralytic i lees. During a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was d is oriented and combative during the night. Which of the following actions should the day shift nurse take? Move the client to a room near the nurses’ station. The day shift nurse should move the client to a room near the nurses’ station to enhance the staff’s ability to keep the client under frequent observation. A nurse is reviewing the laboratory results of a toddler who has hemophilia A. Which of the apt values should the nurse expect? 45 seconds This value is above the expected reference r angel of 30-40 seconds and indicates a risk for spontaneous bleeding, which is a manifestation of hemophilia A. A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? Increase the client’s dietary iron intake. Clients who have rheumatoid arthritis require foods h high in protein, vitamins, and iron to promote tissue repair. The nurse should encourage the client to increase their intake of dietary iron. A nurse is an outpatient mental health facility i s assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? Strict adherence to routines The nurse should identify that a child who has autism spectrum disorder can exhibit strict adherence to routines or rituals, a fixation to specific objects, and resistance to change. A nurse is caring for a c lien that had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)? Place the client in a quiet environment. The nurse should keep the client’s environment quiet to minimize the risk of increasing ICP.