a client is discussing feelings related to a recent loss with the nurse the nurse remains silent when the client says i dont know how i will go on wha
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Nursing Elites

ATI LPN

ATI Medical Surgical Proctored Exam 2019 Quizlet

1. When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?

Correct answer: D

Rationale: In therapeutic communication, silence can offer the client an opportunity to process their emotions and thoughts. By remaining silent, the nurse provides a space for the client to reflect on their own words, facilitating deeper exploration and understanding of their feelings.

2. The nurse is caring for a client who is receiving chemotherapy. Which laboratory result indicates that the client is at risk for infection?

Correct answer: C

Rationale: A white blood cell count of 2,000/mm3 is low and indicates leukopenia, which increases the client's risk for infection. Hemoglobin level and platelet count are not directly indicative of infection risk. Serum creatinine level is related to kidney function, not infection risk.

3. A client with heart failure is prescribed digoxin (Lanoxin). Which sign of digoxin toxicity should the nurse teach the client to report?

Correct answer: B

Rationale: Yellow or blurred vision is a hallmark sign of digoxin toxicity. Digoxin toxicity can affect various body systems, but visual disturbances, such as yellow or blurred vision, are important signs that the client should report immediately. Other signs like increased appetite, weight gain, or nasal congestion are not typically associated with digoxin toxicity. Prompt reporting of visual disturbances can help prevent further complications associated with digoxin toxicity.

4. In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?

Correct answer: C

Rationale: The correct answer is C: Hemoglobin level. Erythropoietin therapy is used to stimulate red blood cell production in patients with chronic kidney disease who often develop anemia due to reduced erythropoietin production by the kidneys. Monitoring the hemoglobin level is essential to evaluate the effectiveness of erythropoietin therapy as an increase in hemoglobin indicates improved red blood cell production and better management of anemia in these patients. Serum creatinine, white blood cell count, and serum potassium levels are important parameters to monitor in CKD patients but are not specific indicators of the effectiveness of erythropoietin therapy for managing anemia.

5. The nurse has completed the admission assessment of a client and has determined that the client's body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client?

Correct answer: A

Rationale: Increasing physical activity is a key component of managing BMI and overall health.

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