ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 9
A pregnant woman presents with sudden onset of severe abdominal pain and dark red vaginal bleeding at 28 weeks gestation. On examination, the uterus is tender, and the fundus feels firm. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: D
Rationale: The most likely cause of the sudden onset of severe abdominal pain and dark red vaginal bleeding with a tender, firm uterus at 28 weeks gestation is abruptio placentae. Abruptio placentae, also known as placental abruption, is the premature separation of the placenta from the uterine wall before delivery. This condition can be life-threatening to both the mother and the fetus, as it can lead to severe bleeding and compromise the oxygen and nutrients supply to the fetus. The presentation typically includes severe abdominal pain, dark red or maroon vaginal bleeding, uterine tenderness, and a firm uterus due to the blood accumulation behind the placenta. Prompt recognition and intervention are crucial to prevent adverse maternal and fetal outcomes.
Question 2 of 9
A patient admitted to the ICU develops delirium characterized by acute onset confusion and agitation. What intervention should the healthcare team prioritize to manage the patient's delirium?
Correct Answer: B
Rationale: The healthcare team should prioritize implementing environmental modifications to promote orientation in a patient with delirium. Delirium is a state of acute confusion and agitation that can be triggered by various factors such as medications, infections, or metabolic disturbances. Environmental modifications involve creating a calm, quiet, and well-lit environment for the patient. Promoting proper orientation through the use of clocks, calendars, and familiar objects can help reduce confusion and improve the patient's understanding of their surroundings. These interventions are non-pharmacological and aim to address the underlying causes of delirium while minimizing the need for additional medications that may have potential side effects. Antipsychotic medications and benzodiazepines should be used judiciously and under close supervision due to the risk of adverse effects in older adults and critically ill patients. Referring the patient to a psychiatrist may be considered if the delirium is complex or if there are underlying psychiatric issues contributing to the presentation.
Question 3 of 9
A patient presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. Slit-lamp examination reveals branching, filamentous opacities extending from the corneal lesion. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: C
Rationale: The described clinical presentation of a yellowish-white spot on the cornea with a ring of inflammation, along with branching, filamentous opacities extending from the corneal lesion, is highly suggestive of fungal keratitis. Fungal keratitis is commonly caused by filamentous fungi such as Fusarium and Aspergillus species. The characteristic finding of branching, filamentous opacities seen on slit-lamp examination is classic for fungal infections of the cornea. It is important to promptly diagnose and treat fungal keratitis since delayed or inadequate management can result in vision-threatening complications.
Question 4 of 9
A patient presents with a displaced fracture of the distal radius and ulna after a fall. What is the preferred initial treatment for this injury?
Correct Answer: A
Rationale: In the case of a displaced fracture of the distal radius and ulna, the preferred initial treatment is typically closed reduction and splinting. Closed reduction involves manually realigning the fractured bones without the need for surgery. Splinting is then utilized to immobilize the wrist and forearm to allow for proper healing of the fracture. This approach is often effective in realigning the bones and stabilizing the injury, allowing for adequate healing without the need for more invasive interventions like surgery. Following the initial management with closed reduction and splinting, the patient's progress will be monitored, and further interventions may be considered based on the specific characteristics of the fracture and the patient's response to treatment.
Question 5 of 9
Before the education plan of the staff nurse can be finalized and implemented, it is best that it is reviewed by the
Correct Answer: A
Rationale: Before finalizing and implementing the education plan for the staff nurse, it is important to have the plan reviewed by the nurse supervisor. The nurse supervisor is directly responsible for overseeing the staff nurses and their education and training needs. They have a good understanding of the staff nurse's current skills, areas for improvement, and training requirements. By involving the nurse supervisor in the review process, you can ensure that the education plan is aligned with the overall goals and needs of the nursing staff and the department. Additionally, the nurse supervisor can provide valuable input and insights to help tailor the education plan to meet the specific needs of the staff nurses under their supervision.
Question 6 of 9
A woman in active labor is experiencing meconium-stained amniotic fluid. What is the nurse's priority action?
Correct Answer: B
Rationale: Meconium-stained amniotic fluid indicates that the fetus may have passed stool in utero, which can lead to potential respiratory problems once born due to meconium aspiration. The priority action for the nurse in this situation is to prepare for immediate delivery to expedite the removal of the fetus from the contaminated environment and provide necessary interventions such as suctioning of the airway to prevent aspiration of meconium. Prompt delivery is crucial to minimize the risk of complications related to meconium aspiration syndrome. Administering oxygen, inserting a urinary catheter, and notifying the neonatal resuscitation team can be important subsequent actions, but the immediate focus should be on delivering the baby.
Question 7 of 9
Nurse Reese is preparing the patient assignment t for the day and needs to assign patients to a midwife and nursing assistant. Which patient should the nurse assign to the midwife because of patient needs that cannot be met by the nursing assistant? A patient requiring________.
Correct Answer: A
Rationale: The patient requiring a dressing change of post-caesarian surgery should be assigned to the midwife because this task involves specialized knowledge and skills related to wound care and post-operative care. Performing a dressing change for a post-caesarian surgery patient requires expertise to ensure proper hygiene, wound healing, and prevention of post-operative complications. This task goes beyond the scope of practice for a nursing assistant and should be done by a healthcare professional with higher qualifications and training, such as a midwife.
Question 8 of 9
The nurse did an admission procedure. The best position to be assumed by Roy is _____.
Correct Answer: B
Rationale: The best position for a patient to assume during an admission procedure, particularly for respiratory assessment, is the semi-fowler position at least 30 degrees. In the semi-fowler position, the patient's head and upper body are elevated to a 30-degree angle. This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and enhancing chest expansion. It also facilitates breathing and allows for better assessment of respiratory status. Additionally, the semi-fowler position helps prevent aspiration and promotes comfort and relaxation for the patient during the admission procedure.
Question 9 of 9
A nurse is caring for a patient who is refusing a prescribed treatment due to cultural beliefs. What action should the nurse take to address the patient's refusal?
Correct Answer: D
Rationale: The nurse should respect the patient's autonomy and collaborate on alternative treatment options. It is essential to honor the patient's cultural beliefs and preferences while also seeking to find a solution that aligns with the healthcare provider's recommendations. By working together with the patient to explore alternative treatment options that are acceptable within the patient's cultural framework, the nurse can promote patient-centered care and foster a trusting relationship with the patient.Ignoring or dismissing the patient's cultural beliefs can lead to decreased patient adherence and trust in the healthcare provider. Providing education and information to help the patient understand the treatment benefits is important, but it should be done in a way that respects the patient's autonomy and cultural perspective.