ATI RN
Multidimensional Basis of Health Protective Behaviors Questions
Question 1 of 5
After insertion of a cheat tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?
Correct Answer: B
Rationale: The correct answer is B: Kinked or obstructed chest tube. When a client with a pneumothorax develops hypotension, neck vein distention, tracheal shift, absent breath sounds, and diaphoresis, it indicates a tension pneumothorax. In this case, the chest tube may be kinked or obstructed, leading to a buildup of pressure in the pleural space. This increased pressure causes a shift in the mediastinum and impairs venous return, resulting in hypotension and other signs of tension pneumothorax. Checking for a kinked or obstructed chest tube is crucial to relieve the pressure and prevent further complications. Other choices are incorrect: A: Infection of the lung does not typically lead to the rapid onset of symptoms seen in tension pneumothorax. C: Excessive water in the water-seal chamber would not cause the described signs of tension pneumothorax. D: Ex
Question 2 of 5
Cristina undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?
Correct Answer: B
Rationale: The correct answer is B: Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis. 1. TIS indicates carcinoma in situ, meaning abnormal cells are present but have not invaded nearby tissues. 2. N0 indicates no abnormal regional lymph nodes, suggesting no spread of cancer to the lymph nodes. 3. M0 indicates no evidence of distant metastasis, indicating the cancer has not spread to other parts of the body. Therefore, the classification TIS, N0, M0 signifies that the lesion is in the early stage, confined to its original location without lymph node involvement or distant spread. Incorrect choices: A: Incorrect - TIS indicates carcinoma in situ, not no evidence of primary tumor. C: Incorrect - The TNM classification is clear, not "Can't assess tumor or regional lymph nodes." D: Incorrect - TIS does not indicate ascending degrees of distant metastasis, and N0 indicates no abnormal lymph nodes, not "
Question 3 of 5
Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
Correct Answer: D
Rationale: Correct Answer: D (The client wears a watch and wedding band) Rationale: 1. MRI machines use strong magnetic fields, which can interact with metal objects like a watch and wedding band, causing them to move or heat up. 2. Movement of metal objects can lead to injury to the client or interfere with the imaging process. 3. It is essential for the client to remove all metal objects before entering the MRI room to ensure safety and accurate imaging. Summary: A: The client lying still is important for a successful MRI scan and does not pose a threat. B: Client asking questions does not pose a threat, as communication is normal during the procedure. C: Hearing thumping sounds is a common experience during an MRI scan and does not pose a direct threat to the client.
Question 4 of 5
A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:
Correct Answer: A
Rationale: The correct answer is A (9 U regular insulin and 21 U NPH) because it closely matches the ratio of 70/30 insulin (70% NPH and 30% regular insulin). Regular insulin acts quickly to cover mealtime needs, while NPH provides intermediate-acting basal insulin. Option B has a higher proportion of regular insulin, which may lead to hypoglycemia. Option C has a lower proportion of regular insulin, which may not cover mealtime needs adequately. Option D has an equal ratio of regular and NPH insulin, not mimicking the 70/30 insulin ratio.
Question 5 of 5
On the third day after a partial thyroidectomy, Proserfina exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a lifethreatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Correct Answer: A
Rationale: Step 1: After thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypoparathyroidism. Step 2: Hypoparathyroidism causes decreased secretion of parathyroid hormone (PTH). Step 3: Decreased PTH leads to decreased calcium reabsorption in the kidneys and increased phosphate levels. Step 4: Low calcium levels cause muscle twitching, hyperirritability, and numbness/tingling. Step 5: Therefore, the electrolyte disturbance most commonly following thyroid surgery is hypocalcemia, making choice A correct. Summary of Incorrect Choices: B: Hyponatremia is not typically associated with thyroid surgery. C: Hyperkalemia is not a common electrolyte disturbance following thyroid surgery. D: Hypermagnesemia is not commonly seen post-thyroid surgery and would not present with the described symptoms.