ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?
Correct Answer: B
Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.
Question 2 of 5
Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.
Question 3 of 5
The nurse is caring for a client with type I diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
Correct Answer: C
Rationale: The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia. Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation. Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.
Question 4 of 5
A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8○0 F (38.2○0 C). What effect may this have on his need for insulin?
Correct Answer: D
Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario. Incorrect choices: A: It will have no effect - Incorrect because infections and fever can impact insulin requirements. B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations. C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.
Question 5 of 5
A client has been diagnosed with type 1 diabetes mellitus. When teaching the client and family how diet and exercise affect insulin requirements, the nurse should include which guideline?
Correct Answer: A
Rationale: The correct answer is A: “You’ll need more insulin when you exercise or increase your food intake.” In type 1 diabetes, exercise and increased food intake can lead to increased glucose levels, requiring more insulin to maintain blood sugar control. Increasing physical activity can enhance insulin sensitivity, necessitating adjustments in insulin dosage. Choices B, C, and D are incorrect as they do not align with the physiological response in type 1 diabetes. B suggests needing less insulin when exercising, which is inaccurate as physical activity can lower blood sugar levels. C implies needing less insulin with increased food intake, which is incorrect as more food can lead to higher glucose levels. D suggests needing more insulin when decreasing food intake, which is not necessarily true as lower food intake can result in lower glucose levels.