ATI RN
Adult Health Nursing Answer Key Questions
Question 1 of 5
As a nurse you are guided that pain is usually described BEST as a phenomenon which is a ________.
Correct Answer: B
Rationale: Pain is best described as a subjective unpleasant experience because it is unique to each individual and is influenced by a variety of factors including emotional, psychological, and cultural elements. Pain cannot be objectively measured or quantified, and therefore it is considered a subjective experience that is reported by the person experiencing it. This is why pain is often assessed using self-report scales and tools to capture the individual's perception of their pain intensity and quality.
Question 2 of 5
The presence of any of these risk factors means that ______.
Correct Answer: B
Rationale: The presence of risk factors indicates an increased likelihood or susceptibility to developing a particular disease. While risk modification and healthy lifestyle choices can help reduce the risk, having these risk factors still increases the overall chances of getting the disease compared to individuals without the same risk factors. It is essential for individuals with risk factors to be proactive in managing their health to mitigate the increased risk.
Question 3 of 5
A patient presents with irritability, muscle weakness, tremors, and weight loss despite increased appetite. Laboratory tests reveal elevated serum thyroid hormone levels and suppressed thyroid-stimulating hormone (TSH) levels. Which endocrine disorder is most likely responsible for these symptoms?
Correct Answer: A
Rationale: The symptoms of irritability, muscle weakness, tremors, weight loss despite increased appetite, along with elevated serum thyroid hormone levels and suppressed TSH levels, are indicative of hyperthyroidism. In hyperthyroidism, the thyroid gland produces an excess amount of thyroid hormone, leading to an overactive metabolism. This results in symptoms such as weight loss, tremors, irritability, and muscle weakness. The elevated levels of thyroid hormone are detected in the laboratory tests, along with low TSH levels due to negative feedback regulation. Therefore, the most likely endocrine disorder responsible for these symptoms is hyperthyroidism.
Question 4 of 5
A patient presents with scrotal pain, swelling, and erythema. On physical examination, there is a tender, fluctuant mass in the scrotum. What is the most likely diagnosis?
Correct Answer: B
Rationale: The most likely diagnosis in this scenario is epididymitis. Epididymitis is an inflammation of the epididymis, a coiled tube at the back of the testicle that stores and carries sperm. Common symptoms include scrotal pain, swelling, erythema (redness), and a tender, fluctuant mass in the scrotum due to an abscess. Risk factors for epididymitis include urinary tract infections, sexually transmitted infections (such as gonorrhea or chlamydia), and recent urological procedures. It is important to differentiate epididymitis from testicular torsion, which would present with sudden, severe testicular pain, absent cremasteric reflex, and a high-riding testicle. Testicular cancer typically presents as a painless mass or swelling in the scrotum, and hydrocele presents as painless scrotal swelling due to a collection of fluid
Question 5 of 5
A postpartum client reports persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?
Correct Answer: C
Rationale: The presence of ecchymosis (bruising) and significant swelling in the perineum despite analgesic medication suggests a potential complication such as a hematoma. A hematoma is a collection of blood that can occur due to trauma or during childbirth. It is important to notify the healthcare provider immediately so that further assessment and interventions, such as drainage of the hematoma, can be initiated promptly to prevent complications and alleviate the client's pain. Applying ice packs or encouraging the client to sit on a donut cushion may provide temporary relief but will not address the underlying issue of a potentially serious hematoma. Administering additional analgesic medication may not be effective in this case if the pain is primarily due to the hematoma. Prompt notification of the healthcare provider is crucial for proper management of this situation.
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