ATI RN
Theory of Health Behavior Change Questions
Question 1 of 5
A male client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
Correct Answer: A
Rationale: The correct answer is A: Auscultate bowel sounds. This is the first nursing action because the client is experiencing abdominal pressure and nausea, which could indicate postoperative ileus. Auscultating bowel sounds helps assess if there is normal bowel function and potential complications. Palpating the abdomen (B) can be uncomfortable for the client post-surgery, and it may not provide immediate information on bowel function. Changing the client's position (C) may not address the underlying issue and can be done after assessing bowel sounds. Inserting a rectal tube (D) is not indicated unless there is a specific medical reason for it, which is not evident in this case.
Question 2 of 5
Marco falls off his bicycle and injuries his ankle. Which of the following actions shows the initial response to the injury in the extrinsic pathway?
Correct Answer: B
Rationale: The correct answer is B: Release of tissue thromboplastin. In the extrinsic pathway of blood coagulation, tissue thromboplastin (also known as tissue factor) is released in response to tissue injury, initiating the clotting cascade. This leads to the activation of factor VII and subsequent steps in the coagulation process. A: Release of Calcium is not specific to the extrinsic pathway and does not directly initiate the clotting cascade. C: Conversion of factors XII to factor XIIa is part of the intrinsic pathway, not the extrinsic pathway. D: Conversion of factor VIII to factor VIIIa is part of the intrinsic pathway, not the extrinsic pathway.
Question 3 of 5
Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates a clear understanding of the importance of hydration and monitoring symptoms in managing HHNS. By recognizing the signs of dehydration and the need to drink more fluids, the client can prevent complications. Choice B is incorrect because consuming soda with sugar can worsen the condition by raising blood glucose levels. Choice C is incorrect as it focuses solely on monitoring blood glucose levels without addressing the crucial aspect of hydration. Choice D is incorrect because eating a snack high in carbohydrates can exacerbate hyperglycemia, leading to further complications.
Question 4 of 5
For a client with Graves' disease, which nursing intervention promotes comfort?
Correct Answer: D
Rationale: The correct answer is D: Maintaining room temperature in the low-normal range. For a client with Graves' disease, they may experience heat intolerance due to increased metabolism. Maintaining a cooler room temperature can help alleviate discomfort. Choice A is incorrect as restricting oral fluids can lead to dehydration, worsening symptoms. Choice B is incorrect as adding extra blankets can increase heat retention, exacerbating discomfort. Choice C is incorrect as limiting high-carbohydrate foods is not directly related to promoting comfort in Graves' disease.
Question 5 of 5
Aldo with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?
Correct Answer: D
Rationale: The correct answer is D: Respiratory alkalosis. In massive pulmonary embolism, there is decreased oxygen exchange in the lungs leading to hypoxia. This causes hyperventilation, leading to a decrease in carbon dioxide levels in the blood, resulting in respiratory alkalosis. Metabolic acidosis (A) and alkalosis (B) are not directly related to pulmonary embolism. Respiratory acidosis (C) would result from hypoventilation, which is not typically seen in pulmonary embolism.