ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 5
What is the M0ST APPROPRIATE nursing diagnosis for this patient?
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for this patient would be "Self-care deficit related to neuromuscular impairment." This diagnosis is supported by the information provided, which indicates that the patient is experiencing neuromuscular impairment that is likely affecting their ability to perform self-care activities. A self-care deficit diagnosis is relevant when a patient is unable to perform activities of daily living independently due to physical or cognitive limitations. In this case, the neuromuscular impairment is likely impacting the patient's ability to engage in self-care tasks, such as feeding, grooming, bathing, and dressing. By identifying and addressing this self-care deficit, the healthcare team can help the patient maintain optimal functioning and independence despite their neuromuscular impairment.
Question 2 of 5
A nurse is preparing to perform a central venous catheter (CVC) dressing change for a patient. What action should the nurse prioritize to minimize the risk of infection?
Correct Answer: C
Rationale: The nurse should prioritize removing the old dressing and applying a new dressing using sterile technique to minimize the risk of infection during a central venous catheter (CVC) dressing change. This is because the most critical step in preventing infection is maintaining a clean and sterile environment around the CVC insertion site. By using sterile technique, the nurse can reduce the introduction of microorganisms that could potentially lead to infection. Wearing sterile gloves and cleaning the insertion site with an alcohol-based antiseptic solution are important steps as well, but the key priority lies in applying the new dressing using sterile technique to prevent contamination and reduce the risk of infection.
Question 3 of 5
A patient presents with chest pain that worsens with exertion and improves with rest. An electrocardiogram (ECG) shows ST-segment depression. Which cardiovascular disorder is most likely responsible for these symptoms?
Correct Answer: A
Rationale: The patient is presenting with chest pain that worsens with exertion and improves with rest, which is characteristic of stable angina. Additionally, ST-segment depression on ECG is a common finding in patients with stable angina. Stable angina is typically caused by coronary artery disease, which leads to partial obstruction of the coronary arteries resulting in inadequate blood flow to the heart muscle during periods of increased demand (such as exertion). The chest pain is usually predictable and reproducible, occurring with similar intensity and duration during episodes of exertion. Rest or nitroglycerin can help relieve the symptoms by increasing coronary blood flow. It is important to differentiate stable angina from unstable angina and acute myocardial infarction, which have different management and prognostic implications.
Question 4 of 5
A patient with a history of heart failure is prescribed carvedilol. Which parameter should the nurse monitor closely during carvedilol therapy?
Correct Answer: C
Rationale: Carvedilol is a beta-blocker primarily used to manage heart failure and hypertension. Monitoring blood pressure closely during carvedilol therapy is crucial because it helps assess the drug's effectiveness in managing heart failure and controlling hypertension. Carvedilol works by blocking certain receptors in the heart and blood vessels, which can lower blood pressure. Monitoring blood pressure fluctuations allows healthcare providers to adjust the dosage accordingly to achieve optimal results and prevent potential complications in patients with heart failure. While monitoring blood glucose levels, serum potassium levels, and liver function tests are essential in managing other conditions or medications, the priority in a patient being prescribed carvedilol for heart failure is to monitor blood pressure levels.
Question 5 of 5
A woman in active labor presents with a prolonged latent phase, characterized by irregular and ineffective contractions. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?
Correct Answer: B
Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.
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