ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response?
Correct Answer: C
Rationale: The correct answer is C because the severity of an anaphylactic reaction can vary greatly from one episode to another in the same patient. Anaphylactic reactions are unpredictable and can be influenced by various factors such as the amount of allergen exposure, individual immune response, underlying health conditions, and concurrent medications. Therefore, it is not possible to reliably gauge the severity of a patient's anaphylactic reaction even if it has occurred repeatedly in the past. Choice A is incorrect because the onset of symptoms alone is not a reliable predictor of the severity of the reaction. Choice B is incorrect as well because there is no set formula to predict that the reaction will be one-third more severe than the patient's last reaction. Choice D is incorrect because stating that the reaction will generally be slightly less severe than the last reaction is also not accurate or supported by evidence.
Question 2 of 5
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons, but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect is theproblem with the 14-year-old?
Correct Answer: B
Rationale: The correct answer is B: Vulvodynia. Vulvodynia is characterized by chronic vulvar pain or discomfort, including stabbing pain and burning, without an identifiable cause. In this case, the young girl is experiencing these symptoms despite not being sexually active, ruling out other conditions like vulvitis (inflammation of the vulva), vaginitis (inflammation of the vagina), and Bartholin's cyst (fluid-filled swelling near the vaginal opening). The absence of sexual activity suggests that the pain is not related to an infection or trauma, further supporting the diagnosis of vulvodynia.
Question 3 of 5
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.
Question 4 of 5
A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the patients skin appears yellow. Which blood tests should be done to further explore this clinical sign?
Correct Answer: A
Rationale: The correct answer is A: Liver function tests (LFTs). Yellow skin can indicate jaundice, a sign of liver dysfunction, often seen in patients with liver issues or chemotherapy-related liver toxicity. LFTs including bilirubin, ALT, AST, and ALP can help assess liver function. B: Complete blood count (CBC) and C: Platelet count are not directly related to yellow skin and would not provide information on liver function. D: Blood urea nitrogen and creatinine are tests for kidney function, not liver function. While kidney dysfunction can sometimes cause yellow skin, LFTs are more specific for assessing liver function in this context.
Question 5 of 5
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
Correct Answer: B
Rationale: Correct Answer: B - Use of a raised toilet seat Rationale: A raised toilet seat helps the patient with Parkinson's disease by providing additional height, making it easier for them to transition from sitting to standing. This aids in improving mobility and reducing the risk of falls. Furthermore, the raised seat can also promote proper positioning for bowel elimination, making the process more comfortable and effective. Incorrect Choices: A: Using a bedpan does not address the issue of transitioning from sitting to standing, nor does it aid in improving bowel elimination for the patient. C: Sitting quietly on the toilet every 2 hours may not directly address the physical challenges the patient is facing in transitioning from sitting to standing. D: Following the outlined bowel program is important, but it does not specifically address the physical support needed to transition from sitting to standing for a patient with Parkinson's disease.
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