ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 5
A nurse is caring for a patient who is refusing a prescribed treatment due to cultural beliefs. What action should the nurse take to address the patient's refusal?
Correct Answer: D
Rationale: The nurse should respect the patient's autonomy and collaborate on alternative treatment options. It is essential to honor the patient's cultural beliefs and preferences while also seeking to find a solution that aligns with the healthcare provider's recommendations. By working together with the patient to explore alternative treatment options that are acceptable within the patient's cultural framework, the nurse can promote patient-centered care and foster a trusting relationship with the patient.Ignoring or dismissing the patient's cultural beliefs can lead to decreased patient adherence and trust in the healthcare provider. Providing education and information to help the patient understand the treatment benefits is important, but it should be done in a way that respects the patient's autonomy and cultural perspective.
Question 2 of 5
A nurse is preparing to assist with a bone marrow biopsy procedure for a patient. What action should the nurse prioritize to ensure patient comfort during the procedure?
Correct Answer: C
Rationale: Prioritizing the application of a topical anesthetic cream to the biopsy site is essential to ensure patient comfort during the bone marrow biopsy procedure. This will help numb the area where the biopsy needle will be inserted, reducing the pain and discomfort experienced by the patient. Administering intravenous sedation may not always be needed for a bone marrow biopsy and should be decided by the healthcare provider based on the patient's individual needs. Providing distraction techniques such as music or relaxation exercises can be helpful, but they may not be as effective at reducing the physical discomfort caused by the procedure. Allowing the patient to eat or drink up to one hour before the procedure is important for other reasons, such as preventing potential complications during sedation or anesthesia, but it is not directly related to ensuring comfort during the biopsy itself.
Question 3 of 5
A nurse is preparing to assist with a transurethral resection of the prostate (TURP) procedure for a patient with benign prostatic hyperplasia (BPH). What action should the nurse prioritize to prevent fluid overload during TURP?
Correct Answer: C
Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly
Question 4 of 5
A patient presents with grouped vesicles on an erythematous base, affecting the lips and perioral region. The patient reports a history of similar episodes triggered by sunlight exposure and stress. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The patient's presentation with grouped vesicles on an erythematous base affecting the lips and perioral region, triggered by sunlight exposure and stress, is classic for herpes simplex labialis, commonly known as cold sores. Herpes simplex virus type 1 (HSV-1) is responsible for cold sores and is highly contagious. Recurrent episodes can be triggered by factors like UV exposure, stress, illness, and hormonal changes. Symptoms typically start with tingling or burning sensations before progressing to grouped vesicles that rupture, forming crusts. Treatment may involve antiviral medications to reduce the severity and duration of symptoms. Perioral dermatitis typically presents with papules and pustules around the mouth, while angular cheilitis involves fissures and inflammation at the corners of the mouth. Allergic contact dermatitis would present with erythema, pruritus, and possibly vesicles in
Question 5 of 5
A patient presents with multiple, flesh-colored, papular lesions with a central dell on the face and trunk. The lesions have a tendency to bleed upon minor trauma and have been increasing in number over time. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The presentation described in the question is classic for basal cell carcinoma (BCC). BCC typically presents as multiple, flesh-colored, papular lesions with a central dell (resembling a pearl-like appearance) on sun-exposed areas such as the face and trunk. These lesions are known to bleed easily upon minor trauma and tend to increase in number over time. BCC is the most common type of skin cancer, often triggered by sun exposure. On the other hand, seborrheic keratosis (choice C) presents as benign, pigmented, stuck-on, waxy, or warty lesions with a rough surface, true bumpy appearance. Squamous cell carcinoma (choice B) usually presents as a scaly, erythematous, rapidly growing nodule, ulcer, or plaque. Actinic keratosis (choice D) presents as rough, scaly patches on sun-exposed areas that can progress to