ATI RN
Adult Health Nursing Study Guide Answers Questions
Question 1 of 5
A postpartum client who delivered vaginally reports difficulty emptying the bladder completely and experiences urinary frequency. What nursing intervention should be prioritized to address this issue?
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.
Question 2 of 5
Which of the following conditions is characterized by chronic hypoxemia, pulmonary hypertension, and right heart failure?
Correct Answer: D
Rationale: Cor pulmonale is a condition characterized by right heart failure secondary to pulmonary hypertension, which is often caused by chronic hypoxemia. Chronic hypoxemia occurs in conditions such as chronic obstructive pulmonary disease (COPD) where there is limited airflow in and out of the lungs, leading to low oxygen levels in the blood. However, the specific characteristic of pulmonary hypertension leading to right heart failure distinguishes cor pulmonale from COPD. Other conditions like idiopathic pulmonary fibrosis (IPF) and pulmonary embolism (PE) may also lead to hypoxemia but are not primarily associated with pulmonary hypertension and right heart failure as in cor pulmonale.
Question 3 of 5
Which of the following immune cells is primarily responsible for coordinating and regulating immune responses by producing cytokines that direct the activities of other immune cells?
Correct Answer: A
Rationale: T helper cells (Th cells) are primarily responsible for coordinating and regulating immune responses by producing cytokines that direct the activities of other immune cells. These cytokines help in activating cytotoxic T cells, B cells, macrophages, and other cells involved in the immune response. Th cells play a crucial role in mounting an effective immune response against infections and diseases by providing the necessary signals to activate and control various immune cells. Thus, T helper cells are considered the central coordinators of the immune system.
Question 4 of 5
Which of the following statements accurately describes the role of natural killer (NK) cells in the immune response?
Correct Answer: A
Rationale: Natural killer (NK) cells play a vital role in the innate immune response by identifying and eliminating virus-infected cells, as well as tumor cells, without the need for prior exposure or activation. NK cells are able to detect abnormal cells by recognizing changes in the cell surface molecules, such as downregulation of MHC class I molecules. Once activated, NK cells release cytotoxic granules containing perforin and granzyme, leading to the destruction of the target cell. This direct killing mechanism is crucial for controlling viral infections and preventing the development of tumors. NK cells do not produce antibodies (option B), present antigens to T cells (option C), or release cytokines to recruit other immune cells (option D) as their primary function in the immune response.
Question 5 of 5
A patient with suspected acute exacerbation of asthma presents with severe dyspnea, accessory muscle use, and inability to speak in full sentences. Which of the following interventions is most appropriate for assessing the severity of the patient's asthma exacerbation and guiding management decisions?
Correct Answer: D
Rationale: In the scenario described, the patient is presenting with severe symptoms of acute exacerbation of asthma, including severe dyspnea, accessory muscle use, and inability to speak in full sentences. In such cases, the most appropriate intervention for assessing the severity of the asthma exacerbation and guiding management decisions is a clinical assessment using standardized severity scores.
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