ATI RN
Nursing a Concept Based Approach Test Bank Questions
Question 1 of 5
A nurse is caring for a child who is hospitalized for an exacerbation of asthma. The nurse is preparing discharge teaching, as the client will be going home on nebulizer treatments and an inhaler. The client and her family members, who are recent immigrants to the United States, speak little English. In addition to enlisting an interpreter to help with the language barrier, what should be a priority for the nurse in developing a teaching plan?
Correct Answer: D
Rationale: Addressing any healing beliefs the family has should be a priority for the nurse in developing a teaching plan for the child with asthma. The family's cultural beliefs and practices may influence their understanding and acceptance of medical treatments. By understanding and respecting the family's beliefs, the nurse can tailor the teaching plan to align with the family's values and ensure better adherence to the treatment plan. This approach promotes effective communication, trust, and collaboration between the healthcare team and the family, which is essential for the child's recovery and ongoing management of asthma. Providing culturally sensitive care is crucial in improving health outcomes and promoting family-centered care in a diverse healthcare setting.
Question 2 of 5
The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
Correct Answer: A
Rationale: In dilated cardiomyopathy, the heart muscle becomes weakened and enlarged, leading to decreased cardiac output. Fatigue is a common manifestation due to the heart's inability to pump effectively. This results in reduced oxygen delivery to tissues, causing fatigue. Lower extremity edema can occur in conditions where the heart is unable to adequately pump blood, leading to fluid buildup in the extremities. Syncope is not typically associated with dilated cardiomyopathy unless severe arrhythmias are present. Dyspnea is commonly seen in heart failure but may not be specific to dilated cardiomyopathy.
Educationally, understanding the pathophysiology of dilated cardiomyopathy helps in differentiating its clinical manifestations from other cardiac conditions. Nurses should be able to recognize these manifestations to provide appropriate care and interventions for clients with dilated cardiomyopathy. This knowledge enhances their assessment skills and aids in developing individualized care plans to improve patient outcomes.
Question 3 of 5
The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.
Correct Answer: A
Rationale: In a toddler diagnosed with tetralogy of Fallot (TOF), the correct anticipated clinical manifestation during the physical assessment is a palpable thrill in the pulmonic area (Option
A). This is due to the characteristic right ventricular outflow tract obstruction present in TOF, leading to increased pressure in the right ventricle and causing a palpable thrill in the pulmonic area.
Nail clubbing (Option
B) is not typically associated with TOF but can be seen in conditions like chronic respiratory or cardiovascular diseases. Cough (Option
C) is a nonspecific symptom and is not a specific clinical manifestation of TOF. Apneic periods (Option
D) are not a typical finding in TOF but may occur in some cases due to hypoxemia.
Educationally, understanding the specific clinical manifestations of congenital heart defects like TOF is crucial for nurses caring for pediatric patients. Recognizing these signs helps nurses provide timely interventions and support to optimize patient outcomes. Palpable thrill in the pulmonic area is a hallmark sign that should alert the nurse to the presence of TOF and guide further assessment and management.
Question 4 of 5
For a client with coronary artery disease, what can the nurse recommend to the client to help decrease cardiac workload and sympathetic nervous system stimulation?
Correct Answer: A
Rationale: For a client with coronary artery disease, physical rest is important to help decrease cardiac workload and sympathetic nervous system stimulation. Physical rest helps reduce the demand on the heart muscle, allowing the heart to work more efficiently. By minimizing physical activity, the client can prevent further strain on the heart and lower the risk of complications such as angina or heart attack. Additionally, reducing physical activity can help lower blood pressure and heart rate, which in turn decreases the workload on the heart. Thus, recommending physical rest is essential in managing and improving outcomes for clients with coronary artery disease.
Question 5 of 5
A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DI
C) is a serious condition characterized by widespread clot formation in the small blood vessels, leading to bleeding tendencies. In DIC, the body consumes clotting factors and platelets faster than they can be replaced, resulting in both bleeding and clotting. Because of this complex pathophysiology, the first line treatment for DIC-related bleeding is to provide replacement of the consumed clotting factors and platelets. Fresh frozen plasma contains clotting factors, and platelets help in stopping bleeding by aiding in clot formation.
Therefore, the administration of fresh frozen plasma and platelets helps to correct the coagulopathy in DIC and manage the bleeding episodes effectively. Aspirin, Warfarin (Coumadin), and Heparin are anticoagulants and would not be appropriate in the treatment of DIC-related bleeding as they can exacerbate the bleeding tendency in this condition.