ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
When percussing a client's chest, the nurse should identify which sound as a normal finding?
Correct Answer: C
Rationale: The correct answer is C: Resonance. When percussing the chest, resonance is the normal sound produced over healthy lung tissue. It indicates air-filled lungs. Hyperresonance (A) is an abnormal sound found in conditions like emphysema. Tympany (B) is a drum-like sound heard over air-filled areas like the stomach. Dullness (D) is heard over solid organs or areas with fluid accumulation, indicating abnormal findings. In summary, resonance is the expected sound over healthy lung tissue, making it the correct choice.
Question 2 of 5
What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours?
Correct Answer: B
Rationale: The correct answer is B: Remittent fever. Remittent fever is characterized by wide temperature fluctuations over normal within a 24-hour period, without returning to normal in between. Intermittent fever has periods of normal temperature between spikes. Relapsing fever has recurring episodes of fevers with symptom-free intervals. Constant fever remains consistently elevated without fluctuations. Therefore, the correct choice is B as it aligns with the described temperature pattern.
Question 3 of 5
A 3 year-old child is brought to the clinic by his grandmother to be seen for scratching his bottom and wetting the bed at night." Based on these complaints
Correct Answer: D
Rationale: The correct answer is D: Regression. In this scenario, the child is showing behaviors such as scratching his bottom and bedwetting, which are common signs of regression in young children. Regression often occurs in response to stress or changes in the child's environment. By selecting this answer, the nurse can explore potential stressors in the child's life and provide appropriate support. A: Not the initial assessment as the symptoms are indicative of a psychological issue rather than a physical problem. B: Allergies are unlikely to cause both scratching bottom and bedwetting. C: Scabies may cause itching but is less likely to cause bedwetting.
Question 4 of 5
The nurse further asked the client to move her tongue side to side & up and down. The nurse is checking what cranial nerve with this process?
Correct Answer: B
Rationale: The correct answer is B: Glossopharyngeal nerve. Moving the tongue side to side & up and down tests the function of the glossopharyngeal nerve (cranial nerve IX), responsible for controlling the muscles of the tongue and throat. The other choices are incorrect because: A: Facial nerve (VII) controls facial expressions, not tongue movements. C: Trigeminal nerve (V) controls chewing and sensation in the face, not tongue movement. D: Abducens nerve (VI) controls eye movement, not tongue movements.
Question 5 of 5
When performing oral care to an unconscious client, which of the following is a special consideration to prevent aspiration of fluids into the lungs?
Correct Answer: D
Rationale: The correct answer is D: Put the client in a side-lying position with the head of the bed lowered. This position helps prevent aspiration of fluids into the lungs by allowing gravity to assist in draining fluids out of the mouth and reducing the risk of them entering the airway. It also helps in preventing choking and aspiration pneumonia. A: Washing hands and observing infection control are important but do not directly address the risk of aspiration. B: Keeping the client dry with a towel does not specifically prevent aspiration and may not be effective in managing oral care for an unconscious client. C: Cleaning the mouth with oral swabs is important, but the technique does not directly address the risk of aspiration compared to positioning the client correctly.