ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A client has undergone a lymph node biopsy. The nurse anticipates that the report will reveal which result if the client has Hodgkin's Lymphoma?
Correct Answer: A
Rationale: Reed-Sternberg cells are large, abnormal lymphocytes that are characteristic of Hodgkin's Lymphoma. They are typically found in the affected lymph nodes of individuals with Hodgkin's Lymphoma when examined under a microscope. Identifying Reed-Sternberg cells in a lymph node biopsy is a key diagnostic feature of Hodgkin's Lymphoma. This distinguishes Hodgkin's Lymphoma from other types of lymphomas that do not have Reed-Sternberg cells.
Question 2 of 9
A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.
Question 3 of 9
A patient presents with scrotal pain, swelling, and erythema. On physical examination, there is a tender, fluctuant mass in the scrotum. What is the most likely diagnosis?
Correct Answer: B
Rationale: The most likely diagnosis in this scenario is epididymitis. Epididymitis is an inflammation of the epididymis, a coiled tube at the back of the testicle that stores and carries sperm. Common symptoms include scrotal pain, swelling, erythema (redness), and a tender, fluctuant mass in the scrotum due to an abscess. Risk factors for epididymitis include urinary tract infections, sexually transmitted infections (such as gonorrhea or chlamydia), and recent urological procedures. It is important to differentiate epididymitis from testicular torsion, which would present with sudden, severe testicular pain, absent cremasteric reflex, and a high-riding testicle. Testicular cancer typically presents as a painless mass or swelling in the scrotum, and hydrocele presents as painless scrotal swelling due to a collection of fluid
Question 4 of 9
After several days in the hospital, the physician ordered the patient to be discharged. Which of the following is a PRIORITY restriction that you should emphasize when he goes home?
Correct Answer: D
Rationale: The priority restriction that should be emphasized when the patient is discharged from the hospital is the lifting of objects not more than 10 lbs. This is important to prevent any strain on the body, especially if the patient is still recovering or weak from their hospitalization. Lifting heavy objects can lead to complications, injuries, or setbacks in the recovery process. It is essential for the patient to follow this restriction to promote healing and avoid any further health issues.
Question 5 of 9
The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?
Correct Answer: B
Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.
Question 6 of 9
A patient expresses frustration with the treatment plan proposed by the healthcare team. What is the most appropriate response from the nurse?
Correct Answer: B
Rationale: The most appropriate response from the nurse when a patient expresses frustration with the treatment plan proposed by the healthcare team is to empathize with the patient's frustration and explore their concerns further. It is important to actively listen to the patient, acknowledge their feelings, and address any questions or uncertainties they may have about the treatment plan. By engaging in open communication and demonstrating empathy, the nurse can foster a therapeutic relationship with the patient and work towards finding a solution that is mutually agreeable and beneficial for the patient's well-being. Dismissing the patient's concerns (Option A) or ignoring their frustration (Option C) can lead to a breakdown in communication and trust, which may ultimately impact the patient's compliance with the treatment plan. Similarly, telling the patient that they have no choice but to follow the treatment plan (Option D) can be perceived as dismissive and confrontational, which is not conducive to promoting patient-centered care.
Question 7 of 9
A patient presents with multiple, flesh-colored, papular lesions with a central dell on the face and trunk. The lesions have a tendency to bleed upon minor trauma and have been increasing in number over time. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The presentation described in the question is classic for basal cell carcinoma (BCC). BCC typically presents as multiple, flesh-colored, papular lesions with a central dell (resembling a pearl-like appearance) on sun-exposed areas such as the face and trunk. These lesions are known to bleed easily upon minor trauma and tend to increase in number over time. BCC is the most common type of skin cancer, often triggered by sun exposure. On the other hand, seborrheic keratosis (choice C) presents as benign, pigmented, stuck-on, waxy, or warty lesions with a rough surface, true bumpy appearance. Squamous cell carcinoma (choice B) usually presents as a scaly, erythematous, rapidly growing nodule, ulcer, or plaque. Actinic keratosis (choice D) presents as rough, scaly patches on sun-exposed areas that can progress to
Question 8 of 9
A retired nurse stops to help in an emergency at the scene of an accident, if the injured party files suit and the, the nurse would probably be covered by
Correct Answer: D
Rationale: The Good Samaritan Law offers legal protection to individuals who voluntarily provide assistance at the scene of an emergency or accident. These laws vary by state, but generally, they grant immunity from civil liability for the individual providing aid as long as they act in good faith and without expectation of compensation. In this case, the retired nurse who stopped to help in the emergency at the scene of an accident would likely be covered by the Good Samaritan Law, protecting her from being sued by the injured party for any unintended consequences of her efforts to assist.
Question 9 of 9
When one has a Cushing disease the focal structure affected is the _______.
Correct Answer: B
Rationale: When one has Cushing's disease, the focal structure affected is the pituitary gland. Cushing's disease is caused by the overproduction of adrenocorticotropic hormone (ACTH) by the pituitary gland. This excess ACTH stimulates the adrenal glands to produce too much cortisol, leading to the symptoms associated with Cushing's disease. Therefore, the primary issue originates in the pituitary gland, not the other structures mentioned in the question.