ATI RN
Nursing a Concept Based Approach to Learning Test Bank Questions
Question 1 of 5
A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP?
Correct Answer: B
Rationale: HELLP syndrome is a serious complication of pregnancy characterized by Hemolysis (H), Elevated Liver enzymes (EL), and a Low Platelet count (LP). Therefore, the correct laboratory finding consistent with the diagnosis of HELLP syndrome is hemolysis. This can be indicated by an elevated lactate dehydrogenase (LDH) level, low haptoglobin, elevated bilirubin, and the presence of schistocytes on a blood smear. The other options (A, C, and D) do not align with the classic presentation of HELLP syndrome.
Question 2 of 5
The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism (PE). The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition?
Correct Answer: D
Rationale: Anticoagulant therapy, specifically heparin, is commonly used as the initial treatment for pulmonary embolism (PE) because it inhibits the formation of additional clots by altering the synthesis of vitamin K-dependent clotting factors. Heparin works quickly and can be administered intravenously to rapidly prevent the clot from growing in size. Warfarin, another anticoagulant, is generally started after heparin therapy is initiated to provide long-term anticoagulation. Major hemorrhage is a potential side effect of anticoagulant therapy, but it is not considered common. The initiation of heparin and warfarin (Coumadin) at the same time is not standard practice due to the differing mechanisms of action and monitoring required for each medication. Anticoagulant therapy is considered first-line treatment for PE, not second-line.
Question 3 of 5
The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs?
Correct Answer: A
Rationale: Supporting a stroke client's sensorimotor needs involves encouraging independence and rehabilitation of the affected side. By encouraging the use of the nonaffected arm for self-care activities like feeding, bathing, and dressing, the nurse is promoting sensorimotor development and function in the affected arm. This intervention will help the client regain strength, coordination, and functionality in the affected arm, which is crucial for their overall recovery and independence. Encouraging the client to actively engage the affected arm promotes neuroplasticity and can improve motor function over time.
Question 4 of 5
A patient has been experiencing diarrhea for the past week. What should the nurse do first when caring for this patient?
Correct Answer: A
Rationale: The first action that the nurse should take when caring for a patient experiencing diarrhea is to ask the patient to describe the number and character of daily stools. This assessment is crucial in determining the severity and possible cause of the diarrhea. By understanding the frequency and consistency of the stools, the nurse can evaluate if the diarrhea is due to an infection, a reaction to medications, dietary factors, or other underlying health issues. Based on this assessment, appropriate interventions can then be implemented, which may include further diagnostic tests, fluid replacement therapy, dietary modifications, or medication administration. It is essential to gather this information first before considering other interventions such as abstaining from oral intake or using over-the-counter antidiarrheal medications.
Question 5 of 5
A female patient who was treated 3 months ago for a urinary tract infection is experiencing the same symptoms now. What should the nurse ask the patient during the health assessment?
Correct Answer: D
Rationale: The nurse should ask the patient if she completed the antibiotic prescribed for the first urinary tract infection because it is important to determine if the initial infection was fully treated. If the antibiotic course was not completed as prescribed, it could lead to a recurrence of the infection due to incomplete eradication of the bacteria. Additionally, incomplete treatment can lead to antibiotic resistance, making it harder to treat future infections. Understanding if the patient followed through with the prescribed treatment is crucial in assessing the current situation and planning appropriate interventions.