ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
A surgical intervention that can cause substantial remission of myasthenia gravis is:
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. Thymectomy involves the surgical removal of the thymus gland, which is often abnormal in individuals with myasthenia gravis. The thymus plays a role in the development of the immune system and can contribute to the autoimmune response seen in myasthenia gravis. By removing the thymus gland, the autoimmune response may be reduced, leading to substantial remission of symptoms. Choice A, Esophagostomy, involves creating a surgical opening into the esophagus and is not a treatment for myasthenia gravis. Choice C, Myomectomy, is the surgical removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, Spleenectomy, is the removal of the spleen and is not a standard treatment for myasthenia gravis.
Question 2 of 5
Which of the ff should qualify as an abnormal result in a Romberg test?
Correct Answer: B
Rationale: Step-by-step rationale: 1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception. 2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal. 3. Hypotension (choice A) is not directly related to the Romberg test. 4. Sneezing and wheezing (choice C) are unrelated to the test. 5. Excessive cerumen in the outer ear (choice D) does not affect proprioception. Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.
Question 3 of 5
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
Correct Answer: A
Rationale: The correct answer is A: Below 70mg/dl. Hypoglycemia is defined as a blood glucose level below 70mg/dl. Symptoms of hypoglycemia include confusion, shakiness, and sweating. Treating hypoglycemia involves administering fast-acting carbohydrates. Choices B, C, and D are incorrect because they describe blood glucose levels that are within the normal or hyperglycemic range, which are not indicative of hypoglycemia. It is essential for the nurse to recognize and promptly address hypoglycemia to prevent serious complications.
Question 4 of 5
The nursing care for the client in addisonian crisis should include which of the following interventions?
Correct Answer: C
Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.
Question 5 of 5
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.