ATI RN
Multidimensional Basis of Health Protective Behaviors Questions
Question 1 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 2 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 3 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.
Question 4 of 5
In an individual with Sjogren's syndrome, nursing care should focus on:
Correct Answer: A
Rationale: Sure! The correct answer is A: moisture replacement. In Sjogren's syndrome, there is a reduction in saliva and tear production, leading to dryness of the eyes and mouth. Moisture replacement helps alleviate symptoms, prevent complications like dental issues, and improve quality of life. Electrolyte balance (choice B) is not directly impacted by Sjogren's syndrome. Nutritional supplementation (choice C) may be helpful but is not the primary focus. Arrhythmia management (choice D) is not typically associated with Sjogren's syndrome.
Question 5 of 5
Nurse Tina prepares a client for peritoneal dialysis. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct first action is to warm the dialysate solution. This is crucial to prevent hypothermia and abdominal discomfort during the procedure. Warming the solution helps maintain the client's body temperature. Assessing for a bruit and a thrill (choice A) is important but not the first step. Positioning the client on the left side (choice C) is needed during the procedure but not the initial step. Inserting a Foley catheter (choice D) is not necessary for peritoneal dialysis.