ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Correct Answer: A
Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.
Question 2 of 5
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?
Correct Answer: D
Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.
Question 3 of 5
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine. 2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects. 3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns. Summary of Incorrect Choices: A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines. B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines. D. Taking antihistamines at bedtime may help with sedation, but it does not address
Question 4 of 5
A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.
Question 5 of 5
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?
Correct Answer: B
Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.