ATI RN
Theories of Health Behavior Change Questions
Question 1 of 5
Antonio with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note:
Correct Answer: A
Rationale: The correct answer is A: miosis, partial eyelid ptosis, and anhidrosis on the affected side of the face. Horner's syndrome results from disruption of sympathetic nerve pathway, leading to these specific symptoms. Miosis (constricted pupil) occurs due to unopposed parasympathetic activity, partial eyelid ptosis (drooping eyelid) due to loss of sympathetic innervation to the eyelid muscle, and anhidrosis (lack of sweating) due to loss of sympathetic innervation to sweat glands. These symptoms are classic in Horner's syndrome. Choice B is incorrect because the symptoms listed are more indicative of general symptoms of lung cancer rather than specific to Horner's syndrome. Choice C is incorrect as it describes symptoms related to brachial plexopathy, not Horner's syndrome. Choice D is incorrect as hoarseness and dysphagia are not typical symptoms of Horner's syndrome.
Question 2 of 5
For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?
Correct Answer: C
Rationale: The correct answer is C because wet-to-dry dressings are used to debride the wound by removing necrotic tissue and promoting healing by secondary intention. Here's the rationale: 1. Wet-to-dry dressings involve moistening the gauze dressing with saline solution before placing it on the wound. 2. As the dressing dries, it adheres to the wound bed and necrotic tissue, helping to remove it during dressing changes. 3. This debridement process helps in promoting healing by allowing healthy tissue to grow and fill in the wound. 4. The wet-to-dry dressing method is specifically indicated for wounds with necrotic tissue, like foot ulcers in diabetic clients. In summary, the other choices are incorrect because A focuses on maintaining a moist environment, B on protecting the wound, and D on preventing infection and minimizing discomfort, which are not the primary purposes of wet-to-dry dressings in this context.
Question 3 of 5
In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says:
Correct Answer: B
Rationale: The correct answer is B because starting birth control pills does not prevent HIV transmission. The nurse should educate the client that HIV can still be transmitted to the baby during pregnancy, childbirth, or breastfeeding. Starting birth control pills does not address the risk of HIV transmission to the baby. Choices A, C, and D demonstrate understanding of HIV transmission risks and prevention methods, showing the need for further education. A acknowledges the risk of vertical transmission, C acknowledges the possibility of preventing transmission, and D recognizes the need for a C-section to reduce the risk of transmission during childbirth.
Question 4 of 5
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
Correct Answer: A
Rationale: Rationale: 1. Platelet count: DIC causes excessive clotting leading to platelet consumption. 2. Prothrombin time (PT): Evaluates the extrinsic pathway of coagulation, prolonged in DIC. 3. Partial thromboplastin time (PTT): Assesses intrinsic pathway, also prolonged in DIC. Therefore, A is correct for monitoring DIC. Summary: B is incorrect because blood glucose and WBC count are not directly related to DIC. C is incorrect as thrombin time, calcium, and potassium levels are not specific to DIC. D is incorrect as fibrinogen level is not included in standard DIC monitoring.
Question 5 of 5
Nurse Evangeline teaches an elderly client how to use a standard aluminum walker. Which of the following behaviors, if demonstrated by the client, indicates that the nurse's teaching was effective?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates the proper technique for using a standard aluminum walker. By pushing the walker forward 12 inches first and then taking small steps while leaning on the walker, the client ensures stability and support. This method helps prevent falls and promotes safe mobility. Option B is incorrect because lifting the walker may lead to instability and increase the risk of falling. Option C is incorrect because supporting weight on the walker while advancing may not provide adequate support. Option D is incorrect because sliding the walker forward may cause the client to lose balance and stability.