ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
Correct Answer: B
Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing. Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.
Question 2 of 5
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
Question 3 of 5
A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education?
Correct Answer: B
Rationale: The correct answer is B: The need for the parents to carry an epinephrine pen. This is the priority for health education because in case of another anaphylactic reaction to walnuts, immediate administration of epinephrine can be life-saving. Immunotherapy (choice A) is not the primary focus in an emergency situation. Maintaining immunization status (choice C) is important but not as critical as having an epinephrine pen. Avoiding high potential allergens (choice D) is important but having an epinephrine pen takes precedence in managing severe allergic reactions.
Question 4 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 5 of 5
A patient has presented with signs and symptoms that are consistent with contact dermatitis. What aspect of care should the nurse prioritize when working with this patient?
Correct Answer: C
Rationale: The correct answer is C: Identifying the offending agent, if possible. This is prioritized in contact dermatitis to prevent further exposure and recurrence. By identifying the specific irritant or allergen, the nurse can guide the patient in avoiding it, leading to effective management. Choices A, B, and D are incorrect because while promoting adequate perfusion, safe use of topical antihistamines, and teaching the use of an EpiPen may be relevant in certain situations, they do not directly address the root cause of contact dermatitis, which is exposure to the offending agent.