ATI: Nurse Logic 2.0: Nursing Concepts (Advance Test)

A. Facial edema *The content of this question emphasizes the concept of client education by determining manifestations the client should be taught to immediately report to the provider. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important for the client to be taught symptoms that should be immediately reported to the provider to prevent or reduce potential harm to herself or the fetus. Facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.

​B. "Let's discuss some strategies you can use when this happens again." *The content of this question emphasizes the concept of client-centered care through the use of therapeutic communication. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The use of therapeutic communication assists the nurse to develop client relationships that foster trust and respect. This response by the nurse offers to provide information, which can reduce anxiety and enhance decision-making. This response by the nurse creates a safe and secure environment, fosters trust and respect, and is appropriate.

C. Determine respiratory status. *The content of this question emphasizes the concept of priority setting by determining priority nursing action for a client experiencing an allergic reaction. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. This item can be answered using both nursing process and the ABC priority setting framework. The client is experiencing angioedema, indicating the possibility of an anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.

C. Supine with head of the bed elevated to 30° *The content of this question emphasizes the concept of safety through selection of the appropriate position for a child who is postoperative following a supratentorial craniotomy. Safety in nursing practice is the minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Following a supratentorial craniotomy, the client should be maintained in a position that facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain. Positioning the client supine with the head of the bed elevated to 30° is appropriate.

A. Take an ABG specimen to the laboratory. *The content of this question emphasizes the concept of leadership by prioritizing completion of assigned tasks. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. When making assignments, a leader should be certain to include a timeline for completion. ABG samples are kept on ice and should be transported immediately to the laboratory or the specimen will deteriorate, which will cause inaccurate and meaningless results. This is the task the nurse should instruct the AP to perform first.

D. Excessive vomiting *The content of this question emphasizes the concept of safety through the identification of a specific manifestation that can lead to metabolic alkalosis. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Metabolic alkalosis is a potential complication of excessive vomiting because of the loss of acid from the body.

C. Lethargy *The content of this question emphasizes the concept of safety through the identification of an initial manifestation of increased ICP. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating potential complications, nurses are better able to predict a needed intervention, which assists in preventing or minimizing physical or psychological harm to the client. Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in the level of consciousness, such as restlessness, irritability, and disorientation, lethargy is the first sign of increased ICP.

A. Cue the client by providing picture cards that portray common needs. *The content of this question emphasizes the concept of client education by determining the appropriate communication strategy to include in teaching to the caregiver of a client who has aphasia. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. Appropriate communication techniques will enhance the caregiver's ability to care for the client, as well as the client's self-expression, thereby ensuring the client's needs are met. Clients who have aphasia have difficulty expressing themselves and understanding what is being said. Using picture cards that portray common needs provides cues for the client and enhances communication. The nurse should include this communication strategy in the teaching.

C. "It is the responsibility of the provider to obtain express consent." *The content of this question emphasizes the concept of professionalism by ensuring understanding of the legal concept of consent. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.

A. Reduced bleeding time *The content of this question emphasizes the concept of safety through an understanding of the purpose of a platelet transfusion. Safety in nursing practice is the minimization of risk factors that can cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others. By recognizing and anticipating expected therapeutic outcomes, nurses are better able to evaluate treatment effectiveness, which is essential in preventing or minimizing physical or psychological harm to the client. Platelets are responsible for triggering the process of blood clotting. In response to intrinsic factors, such as abnormal blood, or extrinsic factors, such as inflammation or damage to blood cells because of trauma, platelets form platelet plugs. The formation of a platelet plug then triggers the more formal process of blood coagulation. Clients who have leukemia are prone to bleeding because of low platelet counts and should, therefore, experience a reduced bleeding time as a result of a transfusion of platelets.

D. Allow the child to manipulate the medical equipment. *The content of this question emphasizes the concept of client-centered care by implementing age-appropriate strategies to prepare a client for a procedure. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. By using age-appropriate strategies, nurses facilitate the provision of individualized, high-quality care. Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.

D. Stop the infusion. *The content of this question emphasizes the concept of priority setting by determining the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. Priority setting is the use of nursing judgment when making decisions about the rank order in which to take nursing actions. Various priority setting frameworks, such as Maslow's Hierarchy of Needs, nursing process, ABC, and safety and risk reduction, can be useful in determining the priority of needed actions. Stopping the infusion is the first action the nurse should take when suspecting a central venous catheter has migrated to the jugular vein. This prevents further damage to vessel and minimizes any additional harm to the client.

*Dietician is correct. Dieticians have expertise related to dietary contributions to maintaining health and treating disease and can offer the team suggestions that promote wound healing and muscle repair. The dietician should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. *Physical therapist is correct. Physical therapists have expertise related to the musculoskeletal system and implements therapeutic treatments that will rebuild and improve strength, teach new skills, and regain mobility. The physical therapist should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation. *Social worker is correct. Social workers have expertise in working with clients and families to resolve issues that arise due to health problems and can link the client with community resources, assist with developing the discharge plan, and resolve conflict. The social worker should be involved in the interdisciplinary team meeting for a client who is being discharged home following an above-the-knee amputation.

C. Discuss the risks associated with leaving with the client. *The content of this question emphasizes the concept of professionalism by determining the legal actions of the nurse when a client leaves a facility against medical advice. Professionalism incorporates legal and ethical principles, as well as compliance with the standards of nursing practice in the provision of safe, quality nursing care that exhibits both accountable and responsible behaviors. Discussing the risks associated with leaving the facility against medical advice with the client is a priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician-prescribed discharge.

D. An adolescent who is 2 days postoperative following an appendectomy *The content of this question emphasizes the concept of leadership through the coordination of client care by making appropriate assignments. Leadership is the process by which nurses use a set of skills that directs and influences others in the provision of individualized, safe, quality client care. When making assignments, a leader should effectively communicate and have knowledge of the skill sets of team members in order to ensure clients receive care by the most appropriate person on the team. The care of an adolescent who is 2 days postoperative following an appendectomy requires postoperative care including education, infection prevention, and medications that require fundamental nursing skills and knowledge; therefore, it is appropriate to assign this client to the nurse who has floated from the labor and delivery unit.

B. "I can have 1 to 2 alcoholic beverages each week." *The content of this question emphasizes the concept of client education by determining which statement by the client indicates effectiveness of the teaching. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. Buspirone is an anxiolytic medication used to treat anxiety, but is different from benzodiazepines because of the fact that it is not a CNS depressant. Because of this, buspirone does not interfere with CNS depressants, such as benzodiazepines, alcohol, or barbiturates, and it is acceptable to have 1 to 2 alcoholic beverages each week. This statement by the client is true and indicates an understanding of the teaching.

B. Elevated temperature *The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.

A. "I will have my husband wear a condom during intercourse." *The content of this question emphasizes the concept of client education by determining the need for additional teaching. Client education is the provision of health-related education to clients to facilitate the acquisition of new knowledge and skills, adoption of new behaviors, and modification of attitudes. It is important that evaluation of teaching is an ongoing process instead of one that occurs only in the final stages of the teaching process. Continual evaluation allows for adjustments to be made as needed to enhance or improve learning. The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of the increased risk for infection. This statement by the client indicates a need for additional teaching.

C. Hypoglycemia *The content of this question emphasizes the concept of safety through the recognition of a potential adverse effect that can result in physical harm. Safety in nursing practice is the minimization of risk factors that can cause harm while promoting quality care and maintaining a secure environment for clients, self, and others. Improving the safety of medications is a major goal of the National Patient Safety Goals. Through the provision of client-centered care and incorporation of evidence-based practice, nurses are able to assist in achieving this goal by preventing or minimizing physical injury. Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.

B. Outcome audit *The content of this question emphasizes the concept of quality improvement by selecting the appropriate audit to conduct when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile. The primary goal of quality improvement is developing and implementing a plan to improve health care services and better meet the needs of clients. To accomplish this goal it is necessary to recognize client and facility issues that impact the provision of safe, quality care, as well as identify gaps between current practices and best practices. Audits are a process of measuring the quality of delivered care so better practices can be developed and implemented when needed. An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.