ATI RN
Adult Health Nursing First Chapter Quizlet Questions
Question 1 of 9
A woman in active labor is receiving intravenous magnesium sulfate for the prevention of eclampsia. What maternal assessment finding indicates magnesium toxicity?
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.
Question 2 of 9
Case finding for PTB n the community requires that the nurse should Identify persons having sputum characterized as ________.
Correct Answer: B
Rationale: Identifying persons with sputum characterized as blood stained is important in case finding for pulmonary tuberculosis (PTB) in the community. Blood stained sputum, also known as hemoptysis, is a common symptom of TB. It occurs when there is bleeding in the respiratory tract, often as a result of damage to the lungs caused by tuberculosis infection. Therefore, the presence of blood in the sputum is a significant clinical finding that should alert healthcare providers, including nurses, to the possibility of TB. Early identification and diagnosis of individuals with blood stained sputum can lead to prompt treatment and the prevention of further transmission of the disease in the community.
Question 3 of 9
Nurse Edna admits a patient from the ER to the medical unit. The patient is very restless with IV lines and a urinary catheter. She was put to bed and the nurse applied a body restraint without the doctor's order. Nurse Edna's action can be liable for _____.
Correct Answer: B
Rationale: Battery in the context of healthcare refers to the intentional and unauthorized touching of a patient. By applying a body restraint without a doctor's order, Nurse Edna has potentially committed battery against the patient. It is important for healthcare providers to obtain proper authorization before implementing any physical restraints on a patient to avoid legal liabilities such as battery.
Question 4 of 9
What would Merle do to keep abreast with the latest trends in peri-operative nursing?
Correct Answer: B
Rationale: To keep abreast with the latest trends in peri-operative nursing, Merle should employ a combination of attending training and seminars, performing researches, and pursuing graduate studies. Attending training and seminars will expose Merle to new information, techniques, and best practices in peri-operative nursing. Performing researches will help Merle stay updated with current developments and evidence-based practices in the field. Pursuing graduate studies will provide Merle with advanced knowledge and skills, allowing for a deeper understanding of peri-operative nursing concepts and practices. By incorporating all of these strategies, Merle can ensure that he remains knowledgeable and competent in his role as a peri-operative nurse.
Question 5 of 9
A woman in active labor is diagnosed with postpartum hemorrhage (PPH) due to uterine atony. What is the priority nursing intervention?
Correct Answer: A
Rationale: The priority nursing intervention for a woman in active labor diagnosed with postpartum hemorrhage (PPH) due to uterine atony is to massage the uterus to promote contraction. Uterine massage helps to stimulate uterine muscle tone and contraction, which can help control bleeding by reducing the size of blood vessels and promoting hemostasis. It is important to address the uterine atony promptly to prevent further blood loss and stabilize the patient's condition. Other interventions such as blood transfusion, administering antibiotics, and elevating the mother's legs can be considered based on the patient's response to the initial intervention of uterine massage.
Question 6 of 9
A nurse is preparing to assist with a lumbar puncture procedure for a patient. What action should the nurse take to maintain procedural asepsis?
Correct Answer: A
Rationale: A nurse should wear sterile gloves and a surgical mask during a lumbar puncture procedure to maintain procedural asepsis. Sterile gloves help prevent contamination of the procedure site and reduce the risk of introducing microorganisms to the puncture site. Surgical masks help minimize the risk of respiratory secretions contaminating the sterile field, which is essential for maintaining asepsis during the procedure. Additionally, proper hand hygiene before and after the procedure is crucial in preventing the spread of infection.
Question 7 of 9
A woman in active labor is receiving intravenous magnesium sulfate for the prevention of eclampsia. What maternal assessment finding indicates magnesium toxicity?
Correct Answer: B
Rationale: Magnesium sulfate is used to prevent eclampsia, but it can lead to toxicity if levels become too high. One common sign of magnesium toxicity is increased deep tendon reflexes, also known as hyperreflexia. This occurs because magnesium is a muscle relaxant, and elevated levels can lead to over-relaxation of muscles, causing an exaggerated reflex response. Other signs of magnesium toxicity include respiratory depression, decreased urine output, and cardiac arrest. Therefore, in a woman receiving intravenous magnesium sulfate during labor, an increase in deep tendon reflexes would indicate potential toxicity and require immediate intervention.
Question 8 of 9
A woman in active labor presents with prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
Correct Answer: A
Rationale: Pelvic floor dysfunction can contribute to a prolonged second stage of labor by impairing the ability of the woman to effectively push during contractions. This can result in inefficient pushing efforts and slow fetal descent. The nurse should assess for signs and symptoms of pelvic floor dysfunction, such as difficulty controlling bowel movements or urine leakage, as addressing this issue may help improve the progress of labor. Maternal fatigue, fetal macrosomia (larger than average baby size), and uterine hyperstimulation are other factors that can impact labor but are less likely to specifically contribute to ineffective pushing efforts and slow fetal descent in the second stage of labor.
Question 9 of 9
A patient presents with sudden-onset unilateral headache, along with ipsilateral ptosis, miosis, and anhidrosis. Which of the following neurological conditions is most likely responsible for these symptoms?
Correct Answer: D
Rationale: The presentation described in the question – sudden-onset unilateral headache along with ipsilateral ptosis, miosis, and anhidrosis – is characteristic of Horner syndrome. Horner syndrome is caused by disruption of the sympathetic nerve pathway and can occur in trigeminal neuralgia. Trigeminal neuralgia is a painful condition affecting the trigeminal nerve commonly characterized by sudden and severe facial pain that can be triggered by various stimuli. The involvement of the sympathetic pathway in trigeminal neuralgia can lead to Horner syndrome symptoms such as ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (lack of sweating) on the affected side of the face. Cluster headaches usually involve severe unilateral pain around the eye, but they do not typically present with Horner syndrome symptoms. Migraine and tension-type headaches also do not typically present with Horner syndrome symptoms.