ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 5
A patient presents with recurrent episodes of venous thrombosis, including deep vein thrombosis (DVT) and pulmonary embolism (PE), despite no apparent provoking factors. Which of the following conditions is most likely to cause these findings?
Correct Answer: D
Rationale: Factor V Leiden mutation is the most common inherited predisposition to venous thrombosis. In this condition, there is a specific mutation in the factor V gene (also known as factor V Leiden) that makes factor V resistant to inactivation by activated protein C. This resistance leads to excessive clot formation, increasing the risk of recurrent venous thrombosis like DVT and PE. Patients with Factor V Leiden mutation may have a history of recurrent unprovoked venous thrombosis at a young age. In comparison, antithrombin III deficiency, protein C deficiency, and protein S deficiency are other inherited thrombophilias that may increase the risk of venous thrombosis, but Factor V Leiden mutation is the most likely cause in this case based on the presentation of recurrent episodes without apparent provoking factors.
Question 2 of 5
The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?
Correct Answer: B
Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.
Question 3 of 5
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 4 of 5
Which of the following statements indicates that the client needs further teaching?
Correct Answer: A
Rationale: The statement "I will have to avoid drinking nonalcoholic beer" indicates a potential misunderstanding as nonalcoholic beer is generally permitted on most diets. The client may need further teaching to clarify this misconception. The other statements indicate a good understanding of the dietary guidelines and do not raise concerns about misunderstanding.
Question 5 of 5
In order not to frighten small children, it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the LAST thing to do in a child is, which of the following, EXCEPT________.
Correct Answer: C
Rationale: When examining a child, especially one who may already be feeling scared or uncomfortable, it is important to prioritize the order of procedures to help maintain their cooperation and reduce their anxiety. Undressing the child is typically done first to ensure a thorough examination can be performed, and it is a less invasive procedure compared to others. Inspection of the throat with a throat stick and inspection of the ears with an otoscope are common procedures that may cause mild discomfort but are often tolerated well by children. Auscultation of the heart is usually done after these initial steps and is not typically as uncomfortable or frightening for children compared to other procedures. Therefore, auscultation of the heart should not be the last thing to do when examining a child to avoid frightening them.
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