ATI RN
Giddens Concepts for Nursing Practice Test Bank Questions
Question 1 of 9
A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client?
Correct Answer: A
Rationale: Given the client's history of type II diabetes mellitus, chronic hypertension, and recent myocardial infarction, the most likely type of shock for the nurse to be prepared to treat in this client is cardiogenic shock. Cardiogenic shock occurs when the heart is unable to pump effectively, leading to inadequate perfusion of vital organs. This can be a complication of myocardial infarction, as damage to the heart muscle can impair its ability to pump blood effectively. Patients with a history of diabetes and hypertension are at increased risk for cardiovascular diseases, such as myocardial infarction, which can lead to cardiogenic shock. Symptoms of cardiogenic shock include hypotension, tachycardia, cool and clammy skin, and altered mental status. Treatment may involve medications to support cardiac function, such as inotropes, and interventions to improve oxygen delivery, such as oxygen therapy and fluid administration.
Question 2 of 9
Following surgery, a patient has not voided for 12 hours. What assessment should the nurse make?
Correct Answer: C
Rationale: Following surgery, a patient not voiding for 12 hours raises concerns for urinary retention, especially if the patient was catheterized during the surgical procedure. With urinary retention, the bladder can become distended and palpating for bladder distention can help determine if the patient is experiencing this issue. If the bladder is distended, interventions may be needed to address the urinary retention to prevent complications such as urinary tract infection or bladder distention-related discomfort. The other assessment options (percuting for gastric tympany, auscultating for bowel sounds, inspecting for edema of the urethra) are not as relevant in assessing a patient's urinary status post-surgery.
Question 3 of 9
Which nursing intervention related to perfusion can be performed independently?
Correct Answer: C
Rationale: Teaching relaxation techniques related to perfusion can be independently performed by a nurse without requiring supervision or intervention from a healthcare provider. This nursing intervention focuses on promoting stress reduction and improving overall perfusion by enhancing circulation and decreasing the workload of the heart. The nurse can educate the patient on various relaxation techniques such as deep breathing exercises, guided imagery, progressive muscle relaxation, and meditation to help optimize perfusion levels. Additionally, teaching relaxation techniques empowers the patient to actively participate in their care and improve their overall well-being.
Question 4 of 9
A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury?
Correct Answer: B
Rationale: Placing the client on the left side and protecting the airway is the most appropriate intervention to protect the client and the fetus from injury during a seizure. This position helps to prevent aspiration of vomitus and maintains an open airway. Placing the client on the left side also enhances maternal and fetal perfusion by reducing pressure on the vena cava, improving blood flow to the placenta, and decreasing the risk of supine hypotensive syndrome. Elevating the client's legs (Option A) and placing the client in the supine position (Option C) are contraindicated as they may worsen the client's condition in the context of preeclampsia and seizure activity. Elevating the head of the bed (Option D) does not address the immediate need to protect the airway and maintain proper positioning during a seizure.
Question 5 of 9
The nurse is counseling a female client who wants to become pregnant. The client was diagnosed with heart failure 3 years ago and is currently in stage II heart failure. What information should the nurse include in her client teaching related to pregnancy and heart failure?
Correct Answer: B
Rationale: Pregnancy can put additional strain on the heart, especially in women with pre-existing heart conditions such as heart failure. Therefore, women with stage II heart failure should receive additional monitoring during pregnancy to ensure their heart function remains stable. This may include more frequent check-ups with a healthcare provider, additional tests such as echocardiograms, and potential adjustments to medications as needed to support the health of both the mother and the baby. It is important to closely monitor and manage the heart failure throughout pregnancy to reduce the risk of complications for both the mother and the unborn child.
Question 6 of 9
A community health nurse is providing education to a group of adults regarding myocardial infarction (MI). When discussing ways to prevent the number of MI-related deaths, which statement by the nurse is inappropriate?
Correct Answer: B
Rationale: While taking a baby aspirin daily can be beneficial for some individuals at increased risk of heart attacks or strokes, it is not a general recommendation for everyone to prevent myocardial infarction (MI). There are potential risks associated with aspirin use, such as gastrointestinal bleeding, which could outweigh the benefits for individuals at low risk of a heart attack. It is important for individuals to consult with their healthcare provider before starting any regimen of daily aspirin therapy. The other statements (A, C, D) focus on increasing awareness, knowledge, and prompt action in response to a suspected MI, which are appropriate measures for prevention and improving outcomes.
Question 7 of 9
The nurse is planning care for a patient beginning hemodialysis. What should be included in this patient’s plan of care? Select all that apply.
Correct Answer: A
Rationale: A. Restrict fluid and protein intake: Patients undergoing hemodialysis typically have restrictions on their fluid and protein intake to prevent fluid overload and minimize the buildup of waste products in the blood that can occur with impaired kidney function.
Question 8 of 9
The nurse is assessing the endocrine system of an older female patient. Which finding is considered an expected age-related change in this system?
Correct Answer: B
Rationale: As individuals age, particularly older women, there tends to be a decrease in facial hair growth. This change is considered a normal part of the aging process and an expected age-related change in the endocrine system. The other options presented, including normal heart tones, thyroid nodules, and an enlarged and firm pituitary gland, are not typically associated with normal aging of the endocrine system.
Question 9 of 9
A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply.
Correct Answer: A
Rationale: 1. Pulses absent in the extremity with the wound (Option A): In chronic venous insufficiency, damaged valves in the veins result in blood pooling in the lower extremities. This can lead to decreased arterial perfusion and impaired circulation, causing weakened or absent pulses in the affected extremity.