ATI RN
Concepts for Nursing Practice 3rd Edition Test Bank Questions
Question 1 of 9
After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?
Correct Answer: B
Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.
Question 2 of 9
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
Correct Answer: C
Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.
Question 3 of 9
During an assessment, the nurse decides to assess a patient’s calcium level. Which action will the nurse take to identify a low calcium level?
Correct Answer: C
Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.
Question 4 of 9
A patient with a compound, open fracture of the femur is scheduled for immediate surgery. Which nursing diagnosis would be most appropriate in the immediate postoperative period?
Correct Answer: B
Rationale: Given that the patient has a compound, open fracture of the femur and is undergoing immediate surgery, the most critical nursing diagnosis in the immediate postoperative period would be the risk for infection. Open fractures are particularly susceptible to infection due to the exposure of the fracture site to external contaminants. Postoperative care should prioritize infection prevention measures like sterile dressing changes, administration of prophylactic antibiotics, and close monitoring for signs of infection such as increased pain, redness, swelling, or drainage from the wound. Mitigating the risk of infection is crucial to prevent complications and promote optimal healing of the fracture. While the other diagnoses are relevant, addressing the risk for infection takes precedence in this scenario.
Question 5 of 9
The nurse is providing care to a client who has experienced several episodes of angina. Which agent does the nurse anticipate being ordered to reduce the intensity and frequency of an angina episode?
Correct Answer: C
Rationale: Nitrates are commonly prescribed for the management of angina. These agents work by dilating blood vessels, which leads to improved blood flow to the heart muscle and decreased workload on the heart. This results in reduced intensity and frequency of angina episodes by increasing oxygen supply to the heart and decreasing its demand. Nitrates can be administered sublingually, orally, or topically to provide prompt relief of chest pain during an angina episode. Thorough patient education should be provided regarding the proper use of nitrates and potential side effects.
Question 6 of 9
What is the most accurate tool for assessing and diagnosing venous thrombosis?
Correct Answer: B
Rationale: Duplex venous ultrasonography is the most accurate tool for assessing and diagnosing venous thrombosis. It is a non-invasive imaging technique that combines Doppler flow studies with conventional ultrasonography. This allows for the visualization of blood flow in the veins and identification of any blood clots or obstructions. Duplex venous ultrasonography is highly sensitive and specific for detecting deep vein thrombosis (DVT) in the lower extremities, making it the preferred imaging modality for diagnosing venous thrombosis. Other imaging modalities like ascending contrast venography, magnetic resonance imaging, and plethysmography are less commonly used due to their disadvantages compared to duplex venous ultrasonography such as invasiveness, cost, and lower accuracy.
Question 7 of 9
The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
Correct Answer: D
Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.
Question 8 of 9
A patient has been vomiting for 4 hours. Which hormone will increase secretion in response to the physiologic changes caused by the vomiting?
Correct Answer: D
Rationale: Vomiting can lead to dehydration and electrolyte imbalances due to the loss of fluids and electrolytes. In response to these physiologic changes caused by vomiting, aldosterone secretion will increase. Aldosterone is a hormone produced by the adrenal glands that acts on the kidneys to increase reabsorption of sodium and water, helping to maintain blood pressure and electrolyte balance. By increasing aldosterone secretion, the body aims to retain more sodium and water to counteract the effects of vomiting and prevent dehydration.
Question 9 of 9
A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, "How will this affect my child's ability to play football in the fall?" How should the nurse respond?
Correct Answer: B
Rationale: Children diagnosed with hypertrophic cardiomyopathy should not participate in competitive sports such as football due to the potential risk of sudden cardiac events. Physical activity and sports with lower intensity may be allowed, but organized competitive sports with high intensity (such as football) are generally contraindicated. It is important for the health care team to prioritize the child's safety and well-being over sports participation in cases of cardiomyopathy. The nurse should communicate this information to the mother to help her understand the importance of limiting the child's physical activities to reduce the risk of complications related to hypertrophic cardiomyopathy.