ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 5
What nursing diagnosis would be MOST appropriate for a client admitted with heart failure?
Correct Answer: B
Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.
Question 2 of 5
A document that lists the medical treatment a person chooses to refuse if unable to make decisions is the:
Correct Answer: B
Rationale: A living will is a legal document that allows an individual to express their wishes regarding medical treatment in the event they become unable to make decisions. It specifically outlines the medical treatments a person chooses to refuse or accept under certain circumstances. It is important to differentiate a living will from a durable power of attorney, which designates someone to make healthcare decisions on behalf of the individual when they are unable to do so, and advance directives, which encompass both a living will and a durable power of attorney for healthcare. The living will serves as a guide for healthcare professionals and family members to honor the individual's preferences for medical care.
Question 3 of 5
Upon admission for an appendectomy, the patient provides the nurse with a document that specifies instructions his healthcare team should follow in the event he is unable to communicate these wishes postoperatively. This document is best known as a/an:
Correct Answer: D
Rationale: An advance directive is a legal document that specifies a person's healthcare preferences and instructions for medical treatment in the event they are unable to communicate their wishes. It typically includes decisions about life-sustaining treatments, resuscitation, and end-of-life care. In the scenario provided, the document provided by the patient to the nurse outlining his healthcare team's instructions postoperatively indicates that he has an advance directive in place to guide his medical care if necessary. In contrast, informed consent is a process in which a patient gives permission for medical treatment after being informed about the risks, benefits, and alternatives. Patient's Bill of Rights outlines the patient's rights within the healthcare system, and an insurance card provides information about the patient's insurance coverage.
Question 4 of 5
The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic manifestation for multiple myeloma does the nurse assess for?
Correct Answer: C
Rationale: Bone pain in the back of the ribs is a classic manifestation of multiple myeloma. Multiple myeloma is a type of cancer that primarily affects plasma cells in the bone marrow, leading to weakened bones and bone pain. Patients with multiple myeloma often experience bone pain in areas such as the ribs, spine, and pelvis. The bone pain is typically persistent and worsens with movement or pressure. Additionally, other common symptoms of multiple myeloma include anemia, kidney damage, recurrent infections, and elevated calcium levels in the blood.
Question 5 of 5
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.