ATI PN Fundamentals 2020 with NGN

Extract:

Question 1 of 5

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

A. Expansion of the upper intercostal spaces. B. Increased convex curve of the cervical spine. C. Increased concave curve of the thoracic spine. D. Unequal height of the shoulders.

Correct Answer: D

Rationale: Unequal shoulder height is a common sign of scoliosis due to spinal curvature.

Question 2 of 5

A nurse is assisting a client who is 4 hr postoperative to get out of bed. The client states, â€œDo not touch me! I can get up by myself.â€ Which of the following responses should the nurse make?

A. I think you need some pain medication before getting out of bed. B. We can talk about this after you have gotten out of bed. C. Why don't you want to be touched? D. I will be next to you and will help if you need me to.

Correct Answer: D

Rationale: Offering standby assistance respects the client's autonomy while ensuring safety.

Question 3 of 5

A nurse is caring for a client who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the nurse take to determine the client's level of pain?

A. Use a communication board to interact with the client. B. Ask an assistive personnel who speaks the same language as the client to interpret. C. Use the Face, Legs, Activity, Cry, Consolability (FLACC) scale to measure the client's pain level. D. Use the FACES pain scale to gauge the client's level of pain.

Correct Answer: C

Rationale: The FLACC scale assesses pain through observable behaviors, suitable for language barriers and postoperative clients.

Question 4 of 5

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

A. Bear weight on the unaffected leg. B. Keep the crutches at the level of the axillae. C. Stand with the crutch tips against the feet. D. Hold the arms straight when walking.

Correct Answer: A

Rationale: The three-point gait involves bearing weight on the unaffected leg while advancing crutches and the affected leg together.

Question 5 of 5

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

A. A client is unable to afford the physical therapy that the provider recommends. B. A client reports being dissatisfied with the temperature of the meals provided. C. A client's visitor becomes dizzy and faints in the client's room. D. A client receives burns from a heating pad. E. A client becomes disoriented and falls out of bed.

Correct Answer: C,D,E

Rationale: C: Visitor injury requires reporting. D: Client injury from equipment is reportable. E: Fall incidents must be documented for safety.

ATI PN Fundamentals 2020 with NGN | Nurselytic

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