ATI RN
Nursing a Concept Based Approach to Learning Test Bank Questions
Question 1 of 5
The nurse is caring for a 76-year-old client with a history of angina. What atypical age- related warning sign of a myocardial infarction should the nurse need to include in client teaching?
Correct Answer: D
Rationale: In older adults, particularly those over 65 years of age, atypical symptoms of a myocardial infarction may occur. Abdominal pain is considered an atypical age-related warning sign because older adults may present with subtle or nonspecific symptoms, such as discomfort or pain in the abdomen, rather than the classic chest pain associated with a heart attack. This atypical presentation can lead to delays in seeking medical attention and diagnosis, which can have serious consequences for the client. Therefore, it is important for the nurse to educate older clients about the possibility of experiencing atypical symptoms, such as abdominal pain, in the context of a myocardial infarction.
Question 2 of 5
The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use?
Correct Answer: B
Rationale: When addressing a client's non-adherence to treatment, a nonjudgmental approach is most effective. This involves showing empathy, understanding, and support without criticizing or condemning the client. By adopting a nonjudgmental attitude, the nurse can create a safe environment for open communication and collaboration to explore the reasons behind the client's non-adherence. This approach helps build trust and rapport, which are essential for promoting positive behavior change and improving treatment adherence. In contrast, being indifferent, demanding, or confrontational can lead to defensiveness, resistance, and further non-adherence in the client.
Question 3 of 5
A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP?
Correct Answer: B
Rationale: HELLP syndrome is a serious complication of pregnancy characterized by Hemolysis (H), Elevated Liver enzymes (EL), and a Low Platelet count (LP). Therefore, the correct laboratory finding consistent with the diagnosis of HELLP syndrome is hemolysis. This can be indicated by an elevated lactate dehydrogenase (LDH) level, low haptoglobin, elevated bilirubin, and the presence of schistocytes on a blood smear. The other options (A, C, and D) do not align with the classic presentation of HELLP syndrome.
Question 4 of 5
The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care?
Correct Answer: B
Rationale: For a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity, keeping the skin clean and dry, and moisturizing areas of dryness is crucial. Patients with PVD often have compromised circulation to the extremities, which can lead to decreased oxygen and nutrient delivery to tissues, increasing the risk of skin breakdown and impaired wound healing. Proper skin care helps prevent skin breakdown, decreases the risk of infection, and promotes overall skin health. Keeping the skin clean and dry helps prevent skin breakdown, while moisturizing areas of dryness helps maintain skin integrity. This intervention focuses on maintaining skin health and preventing complications associated with compromised circulation in patients with PVD.
Question 5 of 5
The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism (PE). The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition?
Correct Answer: D
Rationale: Anticoagulant therapy, specifically heparin, is commonly used as the initial treatment for pulmonary embolism (PE) because it inhibits the formation of additional clots by altering the synthesis of vitamin K-dependent clotting factors. Heparin works quickly and can be administered intravenously to rapidly prevent the clot from growing in size. Warfarin, another anticoagulant, is generally started after heparin therapy is initiated to provide long-term anticoagulation. Major hemorrhage is a potential side effect of anticoagulant therapy, but it is not considered common. The initiation of heparin and warfarin (Coumadin) at the same time is not standard practice due to the differing mechanisms of action and monitoring required for each medication. Anticoagulant therapy is considered first-line treatment for PE, not second-line.