ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
Choose the step of nursing process that identiffies the famiilyy health seeking behavior.
Correct Answer: A
Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.
Question 2 of 9
A 24-year-old woman presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. On pelvic examination, tender nodules are palpated along the uterosacral ligaments. Which of the following conditions is most likely to be responsible for these findings?
Correct Answer: B
Rationale: The symptoms of cyclic pelvic pain, dysmenorrhea (painful menstruation), dyspareunia (painful intercourse), and tender nodules along the uterosacral ligaments are classic findings associated with endometriosis. In endometriosis, tissue similar to the lining of the uterus (endometrium) grows outside the uterus, commonly on the ovaries, fallopian tubes, and pelvic peritoneum. The presence of tender nodules along the uterosacral ligaments is known as "nodularity" and is a characteristic feature of advanced endometriosis. It occurs due to the formation of endometrial implants that respond to hormonal changes during the menstrual cycle, resulting in inflammation, scarring, and pain in affected areas.
Question 3 of 9
Which of the following is the INITIAL eaching given to the patient with ALS and her family?
Correct Answer: C
Rationale: The initial teaching given to a patient with ALS and her family should focus on explaining the disease process, the expected course, and prognosis. Providing this information early on can help the patient and her family understand what to expect, make informed decisions about care and treatment, and prepare emotionally for the challenges ahead. It is important to establish open communication and provide support from the beginning to help the patient and her family cope with the diagnosis and navigate the journey with ALS. While referral to support groups, prevention of complications, and prevention of depression are all important aspects of care for ALS patients, understanding the disease process and prognosis is fundamental to setting realistic expectations and planning for the future.
Question 4 of 9
As a newly 1icensed nurse employed in a tertiary hospital, you are required to attend Continuing Professional Development (CPD) program. When the training program is for the enrichment of nurses in the hospital, it is called __________.
Correct Answer: D
Rationale: In-service training programs are specifically designed to provide continuing education and professional development for employees within a particular organization, in this case, a hospital. These programs are tailored to meet the needs of the staff and enhance their skills and knowledge within their work environment. Since the CPD program in the tertiary hospital is aimed at enriching and supporting the growth of the nurses' knowledge and expertise within the hospital setting, it falls under the category of an in-service training program.
Question 5 of 9
Which of the following medications may produce a false-negative pregnancy test?
Correct Answer: C
Rationale: Anticonvulsant medications, such as phenytoin and phenobarbital, can interfere with pregnancy tests by affecting the levels of human chorionic gonadotropin (hCG) in the body. HCG is the hormone detected in pregnancy tests. These medications may potentially lead to a false-negative result on a pregnancy test for women who are actually pregnant. Therefore, in the case of Almira, who is 6 months pregnant and taking anticonvulsant medication due to the risk of producing a false-negative pregnancy test result, healthcare providers should consider other clinical indicators, such as abdominal cramps and vaginal spotting, to assess her pregnancy status.
Question 6 of 9
A woman in active labor demonstrates persistent fetal malpresentation, with the fetus in a transverse lie position. What nursing intervention should be prioritized to address this abnormal labor presentation?
Correct Answer: C
Rationale: In cases of persistent fetal malpresentation, such as a transverse lie position, a cesarean section is often the safest and most effective intervention to address the abnormal labor presentation. Delivering a baby in a transverse lie position vaginally is associated with high risks, including fetal complications such as umbilical cord prolapse and head entrapment. Therefore, to ensure the safety of both the mother and the baby, a cesarean section is usually the most appropriate and timely intervention to address this situation. It is crucial to prioritize the immediate preparation and facilitation of a cesarean section in cases of persistent fetal malpresentation to prevent potential complications and ensure the best outcome for the mother and the baby.
Question 7 of 9
When the patient turned 69 years old, Orinase was discontinued and NPH insulin is prescribed for her. After several months, she is determined to be suffering from sumogyi effect. Which of the following conditons will most likely result when the patient is receiving too much insulin?
Correct Answer: A
Rationale: When a patient is receiving too much insulin, the most likely result is hypoglycemia, not hyperglycemia. The excess insulin causes the blood glucose level to drop too low, leading to symptoms such as sweating, tremors, confusion, and in severe cases, seizures. The body responds to hypoglycemia by releasing counterregulatory hormones such as glucagon, epinephrine, and cortisol, which work to increase the blood glucose level. This rebound effect, known as the Somogyi effect, can result in the patient experiencing high blood glucose levels after a period of insufficient glucose supply due to excessive insulin administration.
Question 8 of 9
During surgery, the nurse observes an unusual odor emanating from the surgical site. What should the nurse do?
Correct Answer: C
Rationale: If the nurse observes an unusual odor emanating from the surgical site during surgery, it is important to inform the surgeon immediately and assess for signs of infection. Changes in odor can sometimes be an early sign of infection, which requires prompt attention and intervention. By communicating with the surgeon and conducting a thorough assessment, the nurse can help ensure the timely detection and management of any potential complications, such as infection, that may be affecting the patient's surgical outcome. Prompt action in response to unusual observations is crucial to maintaining patient safety and well-being during surgical procedures.
Question 9 of 9
A patient presents with sudden-onset severe scrotal pain, swelling, and erythema. Physical examination reveals a tender, swollen, and high-riding testicle. What is the most likely diagnosis?
Correct Answer: A
Rationale: Given the sudden-onset severe scrotal pain, swelling, and erythema, along with the physical examination findings of a tender, swollen, and high-riding testicle, the most likely diagnosis is testicular torsion. Testicular torsion occurs when the spermatic cord twists, leading to compromised blood flow to the testicle, causing ischemia and severe pain. It is considered a surgical emergency that requires prompt diagnosis and intervention to salvage the affected testicle. Prompt surgical detorsion is necessary to prevent irreversible testicular damage. While epididymitis, testicular trauma, and testicular tumors can also present with scrotal pain and swelling, the presence of a high-riding testicle in this context is highly suggestive of testicular torsion.