ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A patient admitted to the ICU develops delirium characterized by acute onset confusion and agitation. What intervention should the healthcare team prioritize to manage the patient's delirium?
Correct Answer: B
Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.
Question 2 of 9
Patient Sonia, who bas hypothyroidism is given which ONE of the following drug therapies?
Correct Answer: D
Rationale: Patient Sonia, who has hypothyroidism, would benefit from treatment with levothyroxine. Levothyroxine is a synthetic form of the thyroid hormone thyroxine (T4) and is commonly prescribed to replace the deficient thyroid hormone in patients with hypothyroidism. It helps restore the thyroid hormone levels in the body, relieving symptoms such as fatigue, weight gain, and cold intolerance that are characteristic of hypothyroidism. Propranolol is a beta-blocker used for conditions like hypertension, anxiety, and migraines; iron pills are used to treat iron deficiency anemia; and iodine supplementation is not typically used in the treatment of hypothyroidism unless it is due to iodine deficiency.
Question 3 of 9
Which law declares that the policy of the State is to promote and upgrade the practice of profession in the country?
Correct Answer: C
Rationale: RA 9173, also known as the Philippine Nursing Act of 2002, is the law that declares the State policy to promote and upgrade the practice of the nursing profession in the Philippines. This law provides for the regulation and maintenance of high standards of nursing education and practice in the country. It aims to ensure the welfare and professional growth of Filipino nurses and to safeguard the health of the public by maintaining competency and professionalism in the nursing profession. Therefore, RA 9173 is the correct choice that reflects the State's policy to promote and upgrade the practice of the nursing profession in the Philippines.
Question 4 of 9
During a shift handover, the nurse receives information about a patient's condition from the outgoing nurse. What action by the nurse demonstrates effective communication during the handover process?
Correct Answer: C
Rationale: Option C, summarizing key points and asking clarifying questions as needed, demonstrates effective communication during the handover process. This action ensures that the nurse fully understands the information being provided and helps to prevent misunderstandings or missing critical details. By summarizing key points, the nurse confirms their understanding and can ask for clarification on any areas that are unclear. Effective communication during handovers is essential for maintaining patient safety and continuity of care.
Question 5 of 9
Which of the following clinical findings is most consistent with a diagnosis of pneumonia?
Correct Answer: A
Rationale: The clinical findings of inspiratory crackles (also known as rales) and dullness to percussion are most consistent with a diagnosis of pneumonia. Inspiratory crackles are abnormal lung sounds heard on auscultation and are typically due to the presence of fluid or mucus in the alveoli. Dullness to percussion can indicate consolidation of lung tissue, which is a common finding in pneumonia where the alveolar spaces are filled with inflammatory exudate. These findings suggest localized lung pathology and are commonly observed in patients with pneumonia. Hemoptysis and pleuritic chest pain (Choice B) are more suggestive of pulmonary embolism or pleurisy. Clubbing of the fingers and cyanosis (Choice C) are signs of chronic hypoxemia and are not specific to pneumonia. Decreased breath sounds and tracheal deviation (Choice D) are more indicative of conditions such as a pneumoth
Question 6 of 9
Nurse Selma is preparing to administer ofloxacin eardrop on Catherine per Doctor's order. She needs to hold the bottle with her hands to warm up the solution to prevent dizziness for
Correct Answer: B
Rationale: Warming up ofloxacin eardrops before administering is done to prevent dizziness, which can occur if a cold solution is placed in the ear. Holding the bottle with hands for about 1 to 2 minutes is usually sufficient to warm up the solution to a comfortable temperature for the patient. Warming the solution for too long, such as 5-6 minutes, may not be necessary and could potentially waste time. So, the correct duration for warming up ofloxacin eardrops is 1 to 2 minutes.
Question 7 of 9
A postpartum client who delivered via cesarean section expresses concerns about breastfeeding difficulties and worries about insufficient milk supply. What nursing intervention should be prioritized to address the client's concerns?
Correct Answer: A
Rationale: The correct nursing intervention to prioritize in this situation is providing education on techniques to improve latch and milk transfer. Cesarean section deliveries can sometimes pose challenges for breastfeeding initiation, but with proper education and support, many women can successfully breastfeed following a C-section. By teaching the client techniques to improve latch and milk transfer, the nurse can help address the client's concerns about breastfeeding difficulties and worries about insufficient milk supply. This proactive approach empowers the client to overcome breastfeeding challenges and increase their confidence in their ability to breastfeed successfully. Referring the client to a lactation consultant for specialized support may also be beneficial, but providing initial education on latch and milk transfer is crucial in this early postpartum period. Recommending formula feedings or discouraging breastfeeding may not be appropriate interventions, as they can affect the establishment of breastfeeding and undermine the client's breastfeeding goals.
Question 8 of 9
A patient presents with generalized weakness, headache, and difficulty concentrating. Laboratory tests reveal normocytic normochromic anemia, normal iron studies, and elevated serum erythropoietin levels. Which of the following conditions is most likely to cause these findings?
Correct Answer: A
Rationale: The patient in this scenario presents with normocytic normochromic anemia, normal iron studies, and elevated serum erythropoietin levels. These findings are characteristic of anemia of chronic disease, which is commonly seen in patients with chronic kidney disease (CKD). In CKD, there is a decrease in renal production of erythropoietin, leading to reduced stimulation of erythropoiesis and subsequent anemia. The normocytic normochromic anemia pattern is typical in anemia of chronic disease, as opposed to microcytic hypochromic anemia seen in iron deficiency anemia and thalassemia. Aplastic anemia is characterized by pancytopenia, which is not described in the scenario. Therefore, the most likely cause of the patient's presentation is chronic kidney disease.
Question 9 of 9
A patient expresses fear of needles before a scheduled blood draw. What is the nurse's best approach to address this fear?
Correct Answer: B
Rationale: The nurse's best approach to address the patient's fear of needles before a blood draw is to provide the patient with information about relaxation techniques and distraction methods (Option B). Dismissing the patient's fear (Option A), ignoring the fear and proceeding quickly (Option C), or telling the patient that the fear is irrational and unfounded (Option D) would not be helpful and could potentially escalate the patient's anxiety. Providing information on relaxation techniques such as deep breathing or visualization, as well as distraction methods like listening to music or engaging in conversation, can help the patient feel more comfortable and reduce their fear and anxiety during the blood draw procedure. It is important for the nurse to acknowledge and address the patient's concerns in a supportive and empathetic manner to build trust and ensure a successful blood draw experience.