ATI RN
clinical skills questions Questions
Question 1 of 5
A patient presents to the emergency department with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 8°F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder?
Correct Answer: D
Rationale: Rationale: The clinical signs indicate a hypermetabolic state with tachycardia, hypotension, tachypnea, and potential fever, typical of a thyroid storm. The presence of congestive heart failure and atrial fibrillation further support this diagnosis due to the hyperthyroid state exacerbating cardiovascular symptoms. Adrenal crisis (A) would present with hypotension and shock, but not with the hypermetabolic state seen here. Myxedema coma (B) would present with hypothermia, bradycardia, and altered mental status, which are not present in this case. SIADH (C) would typically present with hyponatremia and concentrated urine, which are not seen here.
Question 2 of 5
What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.)
Correct Answer: A
Rationale: Rationale for correct answer A: Altered sleep/rest patterns can disrupt insulin regulation, leading to glucose imbalance and predisposing to diabetic ketoacidosis. Lack of sleep affects hormones that regulate blood sugar levels, increasing the risk of DKA. Summary of why other choices are incorrect: B: Eating disorder can affect blood sugar control but is not a direct cause of DKA. C: Exposure to influenza may trigger stress on the body but is not a psychosocial factor contributing to DKA. D: High levels of stress can impact blood sugar levels but are not specific psychosocial factors leading to DKA.
Question 3 of 5
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Administering levothyroxine is crucial in treating myxedema coma as it helps replace the deficient thyroid hormone. 2. This intervention addresses the underlying cause of myxedema coma, which is severe hypothyroidism. 3. Levothyroxine administration can help reverse the symptoms of myxedema coma and improve the patient's condition. Summary of Incorrect Choices: - B: Encouraging high sodium intake is not appropriate as myxedema coma is associated with fluid retention and sodium may exacerbate this. - C: Passive rewarming interventions are not relevant for myxedema coma, as the condition is not typically related to hypothermia. - D: While monitoring airway and respiratory effort is important in general patient care, it is not a specific intervention for myxedema coma.
Question 4 of 5
The nurse is providing insulin education for an elderly patient with long-standing diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is
Correct Answer: D
Rationale: The correct answer is D: peakless. Insulin glargine is a long-acting insulin with a smooth, consistent release of insulin over 24 hours, providing a steady level of insulin without a pronounced peak. This characteristic helps in maintaining stable blood glucose levels. Options A, B, and C are incorrect as they refer to peak values that do not apply to insulin glargine.
Question 5 of 5
The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte imbalance is
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C: hyperkalemia): 1. Adrenal crisis leads to adrenal insufficiency, causing decreased cortisol levels. 2. Cortisol plays a crucial role in regulating potassium levels. 3. With decreased cortisol, potassium levels can rise, leading to hyperkalemia. 4. Hyperkalemia can result in life-threatening cardiac arrhythmias. Summary: A: Fluid volume excess is not typical in adrenal crisis. B: Hyperglycemia can be present but is not the most significant finding. D: Hypernatremia is not a typical feature of adrenal crisis.