During a patient assessment, the nurse observes signs of distress and discomfort. What action should the nurse take to address the patient's needs?

Questions 164

ATI RN

ATI RN Test Bank

Foundations and Adult Health Nursing Study Guide Answers Questions

Question 1 of 9

During a patient assessment, the nurse observes signs of distress and discomfort. What action should the nurse take to address the patient's needs?

Correct Answer: C

Rationale: The correct action for the nurse to take when observing signs of distress and discomfort in a patient during assessment is to offer emotional support and actively listen to the patient's concerns. Ignoring the patient's distress may lead to worsening of the patient's condition and can be detrimental to the patient's well-being. Documenting the findings and informing the healthcare provider later is important but should not be the immediate response when a patient is in distress. Administering pain medication without further assessment is also not appropriate as the nurse needs to understand the underlying cause of the distress before providing appropriate interventions. Offering emotional support and actively listening to the patient's concerns can help the nurse understand the patient's needs, provide comfort, and potentially address the root cause of the distress.

Question 2 of 9

A patient presents with a pruritic, erythematous rash with edematous plaques and vesicles on the hands and fingers. The patient reports a history of exposure to detergents and frequent hand washing. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: B

Rationale: The presentation of a pruritic, erythematous rash with edematous plaques and vesicles on the hands and fingers in a patient with a history of exposure to detergents and frequent hand washing is most indicative of contact dermatitis. Contact dermatitis can be caused by direct contact with irritants such as detergents or chemicals, leading to skin irritation and inflammation. In this case, the history of exposure to detergents and hand washing suggests that the rash is likely due to irritant contact dermatitis. Atopic dermatitis, psoriasis, and pityriasis rosea do not typically present with the same pattern of rash in response to irritant exposure.

Question 3 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 4 of 9

Nurse Nora monitors the patient, knowing that which finding indicates an adequate contraction pattern?

Correct Answer: A

Rationale: An adequate contraction pattern during labor is characterized by regular contractions occurring at a frequency of three to 5 contractions in a 10-minute period, with resultant cervical dilatation. This pattern indicates efficient uterine activity that is helping to progress labor by dilating the cervix. In option A, the contractions are occurring at an appropriate frequency and are resulting in cervical dilatation, making it the correct choice for indicating an adequate contraction pattern.

Question 5 of 9

Patient Benito ask5 Nurse Virgo, "Why can't the surgeon just take out my pancreas?" The BEST response of Nurse Virgo is

Correct Answer: A

Rationale: The best response of Nurse Virgo is to explain to Patient Benito that his body needs to function well with his pancreas. The pancreas plays a critical role in the digestive system by producing digestive enzymes and hormones that help regulate blood sugar levels. Removing the pancreas would result in serious health consequences and complications, as the body relies on it for essential functions. It is important for the patient to understand the significance of the pancreas and why its removal is not a viable solution.

Question 6 of 9

The nurse is aware that a major difference between Hodgkin's lymphoma and non- Hodgkin's lymphoma is that:_________________

Correct Answer: B

Rationale: One of the major differences between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that Hodgkin's lymphoma is considered potentially curable, while non-Hodgkin's lymphoma is typically not curable. Hodgkin's lymphoma is characterized by the presence of Reed-Sternberg cells, which are not found in non-Hodgkin's lymphoma. Additionally, Hodgkin's lymphoma tends to spread in a more orderly and predictable manner through the lymph nodes, making it easier to treat and potentially cure with the appropriate combination of chemotherapy, radiation therapy, and stem cell transplant. On the other hand, non-Hodgkin's lymphoma is a diverse group of lymphomas that can vary greatly in presentation, behavior, and response to treatment, with some subtypes being more aggressive and resistant to treatment. Therefore, the potential for cure is higher in Hodgkin's lymphoma compared to non-Hodgkin's lymph

Question 7 of 9

A risk is any event that causes problems or benefits on the healthcare institution. The Medical Director knows that potential risks must be identified across the hospital in order to prevent the following, EXCEPT

Correct Answer: C

Rationale: Incident reports are a crucial tool for capturing data on adverse events, near misses, and other incidents within a healthcare institution. These reports help in analyzing patterns, identifying areas for improvement, and implementing quality and safety measures. Therefore, incident reports themselves are not something that needs to be prevented; instead, they are a critical part of the risk management process to enhance patient safety and quality of care.

Question 8 of 9

Twelve hours after vaginal delivery, Nurse Kayla palpates the fundus of a primiparous patient and finds it to be firm, above the umbilicus and deviated to the right. What is the BEST thing for Nurse Kayla to do for the patient?

Correct Answer: C

Rationale: The best thing for Nurse Kayla to do for the patient is to encourage her to ambulate and to void. In this scenario, the fundus being firm, above the umbilicus, and deviated to the right indicates uterine atony with a full bladder. This finding is suggestive of a distended bladder pushing the uterus upwards and to the right. Encouraging the patient to ambulate helps promote uterine contractions, which can aid in the firming up of the uterus. Additionally, emptying the bladder will help the uterus to contract and return to its midline position. This intervention is non-invasive and promotes normal postpartum recovery without the need for medication or excessive manipulation.

Question 9 of 9

Which of the following mechanisms is responsible for the generation of diversity in the antigen-binding sites of immunoglobulins?

Correct Answer: A

Rationale: Somatic hypermutation is the mechanism responsible for generating diversity in the antigen-binding sites of immunoglobulins. During somatic hypermutation, point mutations are introduced into the variable regions of immunoglobulin genes in B cells. These mutations occur randomly and lead to a wide range of amino acid changes in the antigen-binding sites of antibodies. As a result, a diverse repertoire of antibodies with varying specificities for different antigens is created. Gene rearrangement and isotype switching are other mechanisms that contribute to antibody diversity but do not specifically target the antigen-binding sites. Clonal expansion, on the other hand, refers to the proliferation of specific B cell clones after activation by antigens, which amplifies the immune response but does not directly impact the diversity of antigen-binding sites.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days