ATI RN
Stage Theories of Health Behavior Questions
Question 1 of 5
A 76-year-old male client had a thromboembolic right stroke; his left arm is swollen. Which of the following conditions may cause swelling after a stroke?
Correct Answer: C
Rationale: The correct answer is C: Deep vein thrombosis (DVT) due to immobility of the ipsilateral side. After a stroke, immobility can lead to blood pooling in the deep veins, increasing the risk of DVT. This can cause swelling in the affected limb. Choices A and B do not directly relate to swelling post-stroke. Choice D is not relevant to the situation described. Therefore, the correct choice is C due to the increased risk of DVT from immobility post-stroke.
Question 2 of 5
Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
Correct Answer: B
Rationale: The correct answer is B: Pallor, tachycardia, and a sore tongue. In pernicious anemia, the body lacks intrinsic factor needed for vitamin B12 absorption, leading to megaloblastic anemia. Pallor is a common symptom due to decreased red blood cells. Tachycardia occurs as the heart compensates for decreased oxygen-carrying capacity. A sore tongue, known as glossitis, is a classic sign of B12 deficiency. Choices A, C, and D do not align with typical manifestations of pernicious anemia.
Question 3 of 5
Nurse John is caring for clients in the outpatient clinic. Which of the following phone calls should the nurse return first?
Correct Answer: B
Rationale: The correct answer is B because a client with a cast on the right leg reporting a "funny feeling" could indicate a potential circulation or nerve issue, which requires immediate attention to prevent complications. It is important to prioritize urgent physical concerns over other symptoms like itching, nausea, or trouble sleeping. The other options, A, C, and D, are important but not as urgent as the potential complications associated with impaired circulation or nerve function in a client with a leg cast.
Question 4 of 5
A male client with emphysema becomes restless and confused. What step should nurse Jasmine take next?
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to perform pursed lip breathing. This is the appropriate step because the client with emphysema showing restlessness and confusion may be experiencing hypoxia. Pursed lip breathing helps improve oxygenation by slowing down breathing and facilitating better gas exchange. Checking the client's temperature (B) is not the priority in this situation. Assessing the client's potassium level (C) may be important but not the immediate step for a client showing signs of hypoxia. Increasing the client's oxygen flow rate (D) can be considered after assessing the client's response to pursed lip breathing.
Question 5 of 5
Mario has burn injury. After Forty48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide:
Correct Answer: B
Rationale: The correct answer is B (28 gtt/min). To calculate the flow rate in drops per minute (gtt/min), we use the formula: Flow rate (gtt/min) = Volume to be infused (ml) x Drop factor / Time (minutes). In this case, Mario needs 2 liters of IV fluid over 48 hours, which is 2000 ml over 2880 minutes. Using the given drop factor of 10 gtt/ml, we have: 2000 ml x 10 gtt/ml / 2880 min = 20,000 gtt / 2880 min = 6.94 gtt/min. To administer the 2 liters of fluid over 48 hours q12 h, we divide 6.94 gtt/min by 2 (since it's given q12 h) to get 3.47 gtt/min. Rounding up gives us 4 gtt/min for each 12-hour interval. Therefore