ATI Capstone Comprehensive Assessment A | Questions with Verified Answers

ATI Capstone Comprehensive Assessment A | Questions with Verified Answers Assessing the Care Environment for a Client Who is Experiencing Suicidal Ideations -search the client's belonging with the client present. Remo ...

ATI Capstone Comprehensive Assessment A | Questions with Verified Answers Assessing the Care Environment for a Client Who is Experiencing Suicidal Ideations -search the client's belonging with the client present. Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail files, tweezers, matches, razors, perfume, shampoo, plastic bags, and other potentially harmful items from the client's room and vicinity -allow the client to use only plastic eating utensils. Count utensils when brought into and out of the client's room -check the environment for possible hazards (windows that open, overhead pipes that are easily accessible, non-breakaway shower rods, non-recessed shower nozzles) -ensure that the client's hands are always visible, even when sleeping Caring for a Client Who Has Immunosuppression monitor skin and mucous membranes for infection (breakdown, fissures, and abscess) Developing an Emergency Preparedness Plan The Hospital Incident Command System (HICS) for disaster management offers a clear structure for disaster management at the facility level Identifying Reportable Diseases -Nurses are also mandated to report to the proper agency (local health department, state health department) when a client is diagnosed with a communicable disease -a complete list of reportable diseases and a description of the reporting system are available through the Centers for Disease Control and Prevent Web site. Each state mandates which diseases must be reported in that state. There are more than 60 communicable diseases that must be reported to public health departments to allow officials to do the following: ensure appropriate medical treatment of diseases (tuberculosis), monitor for common-source outbreaks (foodborne: hepatitis A), plan and evaluate control and prevention plans (immunizations for preventable diseases), identify outbreaks and epidemics, determine public health priorities based on trends, educate the community on prevention and treatment of these diseases Nationally notifiable diseases: identified at the CDC website and include the following -anthrax, botulism, cholera, congenital rubella syndrome (CRS), diphtheria, giardiasis, gonorrhea, hepatitis A, B, C, HIV, influenza-associated pediatric mortality, legionellosis/legionnaires' disease, lyme disease, malaria, meningococcal disease, mumps, pertussis (whooping cough), poliomyelitis, paralytic, poliovirus infection, nonparalytic, rabies (human or animal), rubella (german measles), salmonellosis, severe acute respiratory syndrome-associated coronavirus disease (SARS-CoV), shigellosis, smallpox, syphilis, tetanus/C. tetani, toxic shock syndrome (TSS) (other than streptococcal), tuberculosis (TB), typhoid fever, vancomycin-intermediate and vancomycin-resistant, viral hemorrhagic fever, staphylococcus aureus (VISA/VRSA) Identifying a Prescription to Clarify With the Provider -caused by damage to sensory nerve fibers resulting in numbness and pain **peripheral neuropathy includes focal neuropathies, caused by acute ischemic damage or diffuse neuropathies, which are more widespread and involve slow, progressive loss. This can lead to complications (foot deformities, ulcers). **autonomic neuropathy can affect nerve conduction of the heart (exercise intolerance, painless myocardial infarction, altered left ventricular function, syncope), gastrointestinal system (gastroparesis, reflux, early satiety), and urinary tract (decreased bladder sensation, urinary retention). It affects the autonomic nervous system, which minimizes manifestations of hypoglycemia (diaphoresis, tremors, palpitations), which can be dangerous for the client -clients who have impaired sensory perception might not feel numbness, pain, or burning managing adverse effects of risperidone orthostatic hypotension -nursing actions: monitor blood pressure and heart rate for orthostatic changes -client education: change position slowly placing a client in side-lying position -position clients, especially those who are unable to move themselves, so that they maintain good body alignment. Frequent position changes prevent discomfort, contractures, pressure on tissues, and nerve and circulatory damage, and they stimulate postural reflexes and muscle tone -use pillows, bath blankets, hand rolls, boots, splints, trochanter rolls, ankle support devices, and other aids to maintain proper body alignment preparing for a sterile dressing change do not turn your back on a sterile field teaching care seat safety motor vehicle injury -place infants and toddlers in a rear-facing car seat until 2 years of age or until they exceed the height and weight limit of the car seat. They can then sit in a forward-facing car seat -use a car seat with a five-point harness for infants and children -all car seats should be federally approved and be placed in the back seat, which is the safest place in the vehicle -infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by manufacturer -toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car seats, should use a forward-facing car seat until they reach the height and weight requirements for a booster seat -newborn infants should be placed in a federally approved car seat at a 45 degree angle to prevent slumping and airway obstruction. The car seat is placed rear facing in the rear seat of the vehicle and secured using the safety belt. The shoulder harnesses are placed in the slots at or below the level of the infant's shoulders. The harness should be snug and the retainer clip placed at the level of the infant’s armpits Educating staff nurses about organ donation -recognize that requests for tissue and organ donations must be made by specifically trained personnel -provide support and education to family members as decisions are being made. Use private areas for any family discussions concerning donation -be sensitive to cultural and religious influences -maintain ventilatory and cardiovascular support for vital organ retrieval evaluating staff performance -have one or more staff members assist with positioning clients. moving them up in bed is a significant cause of back pain and injury -keep your head and neck in a straight line with your pelvis to avoid neck flexion and hunched shoulders, which can cause impingement of nerves in your neck -use smooth movements when lifting and moving clients to prevent injury from sudden or jerky muscle movements -when standing for long periods of time, flex your hips and knees by using a footrest. when sitting for long periods of time, keep your knees slightly higher than your hips -avoid repetitive movements of the hands, wrists, and shoulders. take a break every 15 to 20 min to flex and stretch joints and muscles whenever possible -avoid twisting your spine or bending at the waist (flexion) to minimize the risk for injury evaluating the need for a chest compression vest high-frequency chest compression uses a mechanical chest device combined with nebulization therapy identifying resources to improve health care for migrant farmworkers agency for healthcare research and quality (AHRQ): conducts research to improve the quality, affordability, and safety of healthcare services. uses research data to publish clinical guidelines and recommendations for a variety of health conditions information to include in a change of shift report nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients -formats include face-to-face, audiotaping, or presentation during walking rounds in each client's room (unless the client has a roommate or visitors are present) -an effective report should: include significant objective information about the client's health problems, proceed in a logical sequence, include no gossip or personal opinion, relate recent changes in medications, treatment, procedures, and the discharge plan hand-off or change-of-shift report -performed with the nurse who is assuming responsibility for the client's care -describes the current health status of the client -informs the next shift of pertinent client care information -provides the oncoming nurse the opportunity to ask questions and clarify the plan of care -should be given in a private area (a conference room or at the bedside) to protect client confidentiality priority steps in the time management process time initially spent developing a plan will save time later and help to avoid management by crisis client teaching about basal body temperature method of contraception BBT is the temperature of the body at rest. prior to ovulation, the temperature drops slightly and rises during ovulation. identifying the time of ovulation is a symptom-based method that can be used to facilitate or avoid conception evaluating guardians' understanding of child safety measures avoid sun exposure between 1000 and 1400, wear protective clothing, and apply sunscreen to prevent sunburn sequence of performing an abdominal assessment for most body systems, follow the sequence of first inspecting, then palpating, followed by percussion, and finally auscultation the exception is the abdomen; inspect, auscultate, percuss, and palpate in that order to avoid altering bowel sounds expected findings of autism spectrum disorder -delays in at least one of the following: social interaction, social communication, imaginative play prior to age 3 years -distress when routines are changed -unusual attachments to objects -inability to start or continue conversation -using gestures instead of words -delayed or absent language development -grunting or humming -inability to adjust gaze too look at something else -not referring to self correctly -withdrawn, labile mood -lack of empathy -decreased pain sensation -spending time along rather than playing with others -avoiding eye contact -withdrawal from physical contact -heightened or lowered senses -not imitating actions of others -minimal pretend play -short attention span -intense temper tantrums -showing aggression -exhibiting repetitive movements -typical IQ less than 70 dietary modification for a client who has Crohn’s disease educate the client to eat high-protein, high-calorie, low-fiber foods planning care for a client who has rheumatoid arthritis encourage foods high in vitamins, protein, and iron evaluating the effectiveness of chlorpromazine -treatment of acute and chronic psychotic disorders -schizophrenia spectrum disorders -bipolar disorder: primarily the manic phase -tourette disorder -agitation -prevention of nausea/vomiting through blocking of dopamine in the chemoreceptor trigger zone of the medulla intervention for lorazepam overdose -administer flumazenil for benzodiazepine toxicity to counteract sedation and reverse adverse effects -IV: administer flumazenil to counteract sedation and reverse adverse effects action for insulin administration measure doses accurately, and double-check dosages of high-alert medications (insulin and heparin) with a colleague. check the medication's expiration date teaching about estradiol estrogen either suppresses blood coagulation or promotes it; the effect depends on genetic influences. monitor for embolic event (MI, pulmonary embolism, DVT, stroke) teaching about manifestations of digoxin toxicity monitor for indications of anorexia, nausea, vomiting, visual disturbances, dysrhythmias vitamin k administration following birth administered to prevent hemorrhagic disorders. vitamin K is not produced in the gastrointestinal tract of the newborn until around day 7. vitamin K is produced in the colon by bacteria once formula or breast milk is introduced expected laboratory values in a toddler who has hemophilia A prolonged partial thromboplastin time (aPTT)