ATI RN
Multi Dimensional Care | Exam | Rasmusson Questions
Question 1 of 5
A client with systemic lupus erythematous complains of flank pain. Which laboratory test does the nurse anticipate will be ordered?
Correct Answer: C
Rationale: In the case of a client with systemic lupus erythematous (SLE) experiencing flank pain, the nurse would anticipate that a creatinine test will be ordered. This is because flank pain in a patient with SLE could be indicative of lupus nephritis, a common and serious complication where the kidneys are affected. Creatinine levels are a key indicator of kidney function, and an elevated creatinine level would suggest impaired kidney function, which is crucial information for managing a patient with lupus nephritis. Option A) Platelets: Platelet levels are not typically associated with flank pain in SLE. Platelets are more relevant in conditions like thrombocytopenia, which is a common hematologic manifestation of SLE. Option B) Skin biopsy: Skin biopsy is not directly related to flank pain in SLE. It is a diagnostic procedure used to evaluate skin conditions, not kidney involvement. Option D) Hemoglobin: Hemoglobin levels are important in assessing for anemia, which can be a complication of SLE, but they are not the primary concern when a patient presents with flank pain indicative of possible kidney involvement. Educationally, understanding the rationale behind ordering specific laboratory tests in the context of different symptoms and conditions is crucial for nurses to provide comprehensive care. Connecting clinical manifestations with appropriate diagnostic tests enhances nurses' ability to recognize and respond to potential complications promptly, thereby improving patient outcomes.
Question 2 of 5
A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) The client's incision site has eviscerated. Evisceration refers to the protrusion of an organ through a wound or surgical incision. When a post-operative client with a sutured abdominal incision experiences sharp abdominal pain and bowel protrusion, it indicates evisceration, which is a surgical emergency requiring immediate intervention to prevent complications like infection and further tissue damage. Option B) The client's incision site has lacerated is incorrect because laceration refers to a tear in the tissue, while evisceration specifically involves an organ protruding through a wound. Option C) The client's incisional site is approximated is incorrect as it describes the alignment and closure of wound edges, not the protrusion of bowel. Option D) The client's incisional site has dehisced after is also incorrect as dehiscence refers to the separation of wound edges, not organ protrusion. Educationally, understanding the signs and implications of evisceration is crucial for nurses caring for post-operative patients. Prompt recognition and appropriate communication to the physician are vital to ensure timely intervention and prevent further complications in surgical patients. This knowledge is essential for providing safe and effective patient care in clinical settings.
Question 3 of 5
Most adults with human immunodeficiency virus will exhibit which of the following laboratory values?
Correct Answer: D
Rationale: In adults with human immunodeficiency virus (HIV), the correct answer is option D: Lower than normal number of CD4+ T-cells and CD8+ T-cells are normal. This is because HIV primarily targets CD4+ T-cells, leading to a decrease in their count. CD8+ T-cell levels may remain normal as they are involved in the immune response to HIV. Option A is incorrect because in HIV, CD4+ T-cell levels are typically lower. Option B is incorrect as CD8+ T-cell levels may be higher in response to the infection but not higher than normal. Option C is incorrect as both CD4+ and CD8+ T-cell levels are usually low in HIV. Educationally, understanding the immune response in HIV is crucial for healthcare professionals to effectively manage and treat patients with the virus. Monitoring CD4+ T-cell levels is essential in assessing disease progression and guiding treatment decisions. This knowledge helps in providing optimal care and support to individuals living with HIV.
Question 4 of 5
A nurse is teaching a client who has fibromyalgia about strategies that might help reduce her symptoms. What should the nurse include in the client education?
Correct Answer: C
Rationale: In educating a client with fibromyalgia about symptom management, it is crucial to emphasize the importance of establishing a regular sleep pattern, which is the correct option (C). This is because sleep disturbances are common in fibromyalgia and can exacerbate symptoms. By promoting a consistent sleep routine, the nurse can help improve the client's overall well-being and minimize pain and fatigue. Option A, avoiding exercise during flare-ups, is incorrect because regular, gentle exercise is actually beneficial for managing fibromyalgia symptoms. Exercise can help improve flexibility, reduce pain, and enhance overall quality of life for individuals with fibromyalgia. Option B, recommending high-impact exercises like running, is incorrect as these types of exercises can actually worsen symptoms by putting additional strain on the muscles and joints, leading to increased pain and fatigue. Option D, suggesting an increase in calcium and caffeine intake, is also incorrect as there is no strong evidence linking these specific dietary factors to symptom improvement in fibromyalgia. In fact, excessive caffeine intake can disrupt sleep patterns, which is counterproductive for individuals with fibromyalgia. Educationally, this rationale highlights the importance of individualized care in managing fibromyalgia and the significance of evidence-based recommendations in promoting symptom relief and overall well-being for clients with this condition.
Question 5 of 5
What is a sign of inadequate perfusion?
Correct Answer: B
Rationale: Inadequate perfusion refers to the insufficient delivery of oxygen and nutrients to tissues due to compromised blood flow. Pallor in toes, as indicated in option B, is a sign of inadequate perfusion. When perfusion is inadequate, there is reduced blood flow to the extremities, leading to a pale or whitish appearance in the toes due to decreased oxygen supply. This is a critical indicator that tissue is not receiving adequate perfusion and may be at risk for damage or necrosis. Intact sensation (option A) does not directly correlate with perfusion status. While intact sensation is important for assessing nerve function, it is not a reliable indicator of perfusion adequacy. Bounding pulses (option C) are actually a sign of increased blood flow and may be present in conditions such as fever or inflammation, not inadequate perfusion. Pink fingers (option D) suggest good circulation and oxygenation, which is contrary to the expected pallor seen in inadequate perfusion. In an educational context, understanding the signs of inadequate perfusion is crucial for healthcare professionals to assess and address circulatory issues promptly. Recognizing these signs can help prevent complications such as tissue damage, organ dysfunction, or even loss of limb. Educating healthcare providers on these indicators enables them to provide timely interventions and improve patient outcomes.