ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
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 9
Nurse Pat promised to a post- surgical patient, that she would come back to assist in his of ambulation after carrying out the physician's order. This follows the principle
Correct Answer: D
Rationale: Fidelity is a principle in nursing ethics that pertains to being faithful or loyal to commitments and promises made to patients. When Nurse Pat promised to come back to assist in the patient's ambulation after carrying out the physician's order, she is demonstrating fidelity by fulfilling her commitment to the patient's care. This principle helps build trust between the nurse and the patient, ensuring continuity and quality of care.
Question 3 of 9
A patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed a metered-dose inhaler (MDI) with a spacer. Which instruction should the nurse include in the demonstration of MDI use?
Correct Answer: A
Rationale: The correct instruction for using a metered-dose inhaler (MDI) with a spacer for a patient with COPD is to inhale slowly and deeply while pressing the canister. This technique helps ensure that the medication reaches the lungs effectively. Inhaling slowly and deeply allows the medication to be properly delivered to the airways, maximizing its effectiveness in treating the symptoms of COPD. This instruction helps the patient coordinate pressing the canister with their inhalation, which is crucial for proper medication delivery in COPD management.
Question 4 of 9
A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?
Correct Answer: A
Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine
Question 5 of 9
Verbal communication is the use of words when talking to your patient. The use of literal words when you speak is the :
Correct Answer: C
Rationale: Verbal communication involves the use of words and language to convey information. The content refers to the actual words and messages being communicated. In verbal communication with your patient, the content of what you say is key to ensuring effective communication that is clear, accurate, and easily understood. Therefore, the use of literal words when speaking to your patient embodies the content of your communication.
Question 6 of 9
One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse's INITIAL intervention?
Correct Answer: C
Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.
Question 7 of 9
It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:
Correct Answer: B
Rationale: The nurse's appropriate response is to provide the requested information clearly and directly. In this case, the client asked for the time, so the best response is to say "It is 10 o'clock" to answer their question promptly. Options A, C, and D do not address the client's question and may be perceived as dismissive or unhelpful.
Question 8 of 9
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 9 of 9
The nurse is aware that a major difference between Hodgkin's lymphoma and non- Hodgkin's lymphoma is that:_________________
Correct Answer: B
Rationale: One of the major differences between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that Hodgkin's lymphoma is considered potentially curable, while non-Hodgkin's lymphoma is typically not curable. Hodgkin's lymphoma is characterized by the presence of Reed-Sternberg cells, which are not found in non-Hodgkin's lymphoma. Additionally, Hodgkin's lymphoma tends to spread in a more orderly and predictable manner through the lymph nodes, making it easier to treat and potentially cure with the appropriate combination of chemotherapy, radiation therapy, and stem cell transplant. On the other hand, non-Hodgkin's lymphoma is a diverse group of lymphomas that can vary greatly in presentation, behavior, and response to treatment, with some subtypes being more aggressive and resistant to treatment. Therefore, the potential for cure is higher in Hodgkin's lymphoma compared to non-Hodgkin's lymph