ATI RN
Skin Integrity and Wound Care Questions Questions
Question 1 of 5
The nurse is caring for a client who presents with acute malaise, muscle aches, and fever. Which additional assessment findings should the nurse recognize as consistent with influenza? Select the one that does not apply
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Influenza typically presents with symptoms such as malaise, muscle aches, fever, and a nonproductive cough. Hypotension is not a common symptom of influenza. It is more indicative of other conditions like sepsis or dehydration. Difficulty urinating is not typically associated with influenza either. A lack of recent vaccinations (choice A) can contribute to susceptibility to influenza, and a nonproductive cough (choice B) is a common respiratory symptom seen in influenza cases. Thus, hypotension is the outlier among these assessment findings.
Question 2 of 5
An older adult client is admitted with pneumonia. Which manifestations would the nurse expect to find when assessing this client? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Hemoptysis. In pneumonia, hemoptysis (coughing up blood-tinged sputum), is a common symptom due to inflammation and infection in the lungs. It is caused by the destruction of lung tissue and blood vessels. Increased appetite (B) is unlikely as pneumonia typically causes a decreased appetite due to feeling unwell. Cough (C) is a common manifestation of pneumonia, but it is not specific to pneumonia alone. Tachypnea (D) is also a common symptom of pneumonia due to the body's attempt to increase oxygen intake, but it is not as specific as hemoptysis in this context.
Question 3 of 5
The provider has ordered fluid administration for a pediatric client with pneumonia. The client weighs 81.6 lb (37 kg). The nurse should expect to administer ________ mL of fluid per day for this client.
Correct Answer: A
Rationale: To calculate fluid administration for a pediatric client, use the formula: 100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, and 20 mL/kg for each kg above 20 kg. For a 37 kg client, the calculation is: (10 kg x 100 mL) + (10 kg x 50 mL) + (7 kg x 20 mL) = 1840 mL/day (Answer A). This is the correct answer because it follows the appropriate formula based on the client's weight. Choices B, C, and D are incorrect as they do not follow the correct calculation method for fluid administration based on weight.
Question 4 of 5
List the pathophysiology concepts related to the onset of sepsis in sequential order.
Correct Answer: A
Rationale: The correct sequence for the pathophysiology of sepsis onset is as follows: 1. Macrophage-producing cytokines are released. 2. Endotoxin released by microorganisms triggers an inflammatory response. 3. Neutrophils arrive and multiply, leading to capillary occlusion. 4. Vasodilation occurs with increased capillary permeability and fluid leak. Macrophage cytokines initiate the cascade of events by signaling the immune response. Endotoxin release exacerbates inflammation. Neutrophil accumulation causes capillary blockage. Vasodilation and increased permeability follow, leading to septic shock. Other choices are incorrect as they do not follow the correct sequence of events in sepsis pathophysiology.
Question 5 of 5
The nurse is providing teaching to parents about urinary tract infections (UTIs) in preschool children. The nurse should inform the parents that which of the following are common symptoms of UTI in this age group? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Urinary urgency. In preschool children, common symptoms of UTI include urinary urgency due to the irritation of the bladder lining by the infection. Elevated blood pressure is not a common symptom of UTI in this age group. Dysuria, or painful urination, can also be a symptom but is less common in preschool children. Fever is a common symptom of UTI, but it is not specific to this age group as it can occur in various infections. Therefore, the most specific and common symptom of UTI in preschool children is urinary urgency.