Questions 9

ATI RN

ATI RN Test Bank

Adult Health Nursing Answer Key Questions

Question 1 of 5

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 5

When conducting a nursing history on the Health Perception, Health Management pattern of functioning what is the APPROPRIATE question to be asked pre-operatively?

Correct Answer: C

Rationale: When conducting a nursing history on the Health Perception, Health Management pattern of functioning pre-operatively, an appropriate question to ask would be "Are you aware of risk factors for your disease?" This question helps assess the individual's level of awareness and understanding of their health condition and the factors that may impact it. Understanding the patient's knowledge of their risk factors can help guide interventions and education before surgery to optimize their health outcomes. Asking about perceived wound healing, shortness of breath, or weight changes may not be directly related to the patient's awareness of their disease risk factors in the pre-operative setting.

Question 3 of 5

What is the PRIORITY of care for patient diagnosed with Guillain-Barre Syndrome?

Correct Answer: A

Rationale: The priority of care for a patient diagnosed with Guillain-Barre Syndrome is the maintenance of respiratory function. Guillain-Barre Syndrome can cause paralysis, including respiratory muscles, leading to respiratory failure. Ensuring adequate ventilation and oxygenation is crucial to prevent complications such as respiratory failure and the need for mechanical ventilation. Monitoring for signs of respiratory distress, such as shortness of breath, decreased oxygen saturation, and diminished lung sounds, is essential in providing prompt intervention and support for the patient's respiratory needs. Other aspects of care, such as prevention of decubitus ulcers, control of urinary tract infections, and replacement of fluid and electrolytes, are also important but not as immediate or life-threatening as ensuring adequate respiratory function in these patients.

Question 4 of 5

A patient admitted to the ICU develops delirium characterized by acute onset confusion and agitation. What intervention should the healthcare team prioritize to manage the patient's delirium?

Correct Answer: B

Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.

Question 5 of 5

A woman in active labor is experiencing meconium-stained amniotic fluid. What is the nurse's priority action?

Correct Answer: B

Rationale: Meconium-stained amniotic fluid indicates that the fetus may have passed stool in utero, which can lead to potential respiratory problems once born due to meconium aspiration. The priority action for the nurse in this situation is to prepare for immediate delivery to expedite the removal of the fetus from the contaminated environment and provide necessary interventions such as suctioning of the airway to prevent aspiration of meconium. Prompt delivery is crucial to minimize the risk of complications related to meconium aspiration syndrome. Administering oxygen, inserting a urinary catheter, and notifying the neonatal resuscitation team can be important subsequent actions, but the immediate focus should be on delivering the baby.

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