ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
Which nursing diagnosis takes highest priority for a client with hyperparathyroidism?
Correct Answer: B
Rationale: The correct answer is B: Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing. This nursing diagnosis takes highest priority for a client with hyperparathyroidism because the client is at risk for skin breakdown due to edema, skin fragility, and poor wound healing caused by the condition. Skin integrity is crucial for preventing infection and promoting overall health. Choice A is incorrect because hyperparathyroidism is not related to thyroid hormone excess, but rather to parathyroid hormone excess. Choice C is incorrect because body image disturbance is not the highest priority compared to the risk of skin breakdown. Choice D is incorrect because hyperparathyroidism typically leads to hypercalcemia and not imbalanced nutrition related to thyroid hormone excess.
Question 2 of 5
Mrs. Tan was prescribed with nitroglycerin. Nurse Amalia teaches her about the common side effect of the drug which includes:
Correct Answer: D
Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use. Explanation of other choices: A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels. B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system. C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.
Question 3 of 5
In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?
Correct Answer: B
Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.
Question 4 of 5
Emil, just had a thyroidectomy this morning. Upon awakening, he complains of circumoral tingling, has a positive Chvostek’s sign and positive Trousseau’s sign. Nurse Ofel assesses this to be an indication of:
Correct Answer: A
Rationale: Rationale: The correct answer is A, overstimulation of the parathyroid hormone. After a thyroidectomy, there is a risk of unintentional damage to the parathyroid glands, leading to hypoparathyroidism. Circumoral tingling, positive Chvostek’s sign, and positive Trousseau’s sign are classic signs of hypocalcemia resulting from parathyroid insufficiency. Choices B, C, and D are incorrect because they do not explain the specific symptoms observed in Emil, which are indicative of low calcium levels due to parathyroid dysfunction.
Question 5 of 5
Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.