ATI RN
Multidimensional Basis of Health Protective Behaviors Questions
Question 1 of 5
A male client has jugular distention. On what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distention?
Correct Answer: C
Rationale: The correct answer is C: Raised 30 degrees. Placing the client's head at a 30-degree angle allows gravity to pull the blood down from the head, providing a more accurate reading of jugular vein distention. In a supine position (choice D), the distention may be underestimated. High Fowler's position (choice A) may increase venous return and elevate the jugular vein further. Raising the bed by 10 degrees (choice B) may not provide enough angle for optimal blood flow.
Question 2 of 5
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?
Correct Answer: D
Rationale: The correct answer is D. Diabetes insipidus results from inadequate production or action of antidiuretic hormone, leading to excessive urine output and dilute urine. In this case, the sudden rise in urine output above 200 ml/hour indicates a large volume of dilute urine being excreted. Therefore, the urine osmolality will be low (below normal) due to its diluteness. On the other hand, the serum osmolality will be high (above normal) because the body is unable to retain water properly, leading to dehydration and concentration of solutes in the blood. This imbalance in osmolality levels between urine and serum supports the nurse's suspicion of diabetes insipidus. Incorrect choices: A: Above-normal urine and serum osmolality levels - This is incorrect because in diabetes insipidus, urine osmolality is low (dilute) and serum osmolality is high. B: Below-normal urine and serum os
Question 3 of 5
Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Correct Answer: D
Rationale: The correct answer is D: Below-normal serum potassium level. In HHNS, there is severe hyperglycemia leading to osmotic diuresis and dehydration. As a result, potassium is lost in the urine, causing hypokalemia. This can lead to life-threatening cardiac arrhythmias. Elevated serum acetone level (A) and serum ketone bodies (B) are typically seen in diabetic ketoacidosis, not in HHNS. Serum alkalosis (C) is not commonly associated with HHNS.
Question 4 of 5
Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?
Correct Answer: A
Rationale: The correct answer is A, as hemoptysis in pulmonary embolism is often due to alveolar damage in the infarcted area caused by the blockage of blood flow to the lung tissue. This leads to inflammation and subsequent bleeding. Choice B is incorrect because major blood vessel involvement does not directly lead to hemoptysis. Choices C and D are incorrect as they are too general and do not specifically address the mechanism of hemoptysis in pulmonary embolism.
Question 5 of 5
The nurse knows that neurologic complications of multiple myeloma (MM) usually involve which of the following body system?
Correct Answer: C
Rationale: The correct answer is C: Renal dysfunction. Neurologic complications in multiple myeloma often manifest as renal dysfunction due to the deposition of abnormal proteins in the kidneys, leading to kidney damage. This can result in symptoms like proteinuria, renal insufficiency, and ultimately renal failure. The other choices, brain (A), muscle spasm (B), and myocardial irritability (D), are less likely to be directly associated with neurologic complications of multiple myeloma. Brain involvement in MM is rare, muscle spasms are not a common neurologic complication, and myocardial irritability is more related to cardiac function rather than neurologic complications in MM.