ATI LPN
Questions on the Integumentary System Questions
Question 1 of 5
Which statement should the nurse identify as the expected outcome for a client experiencing acute pain?
Correct Answer: B
Rationale: The correct answer is B because participation in self-care activities indicates effective pain management and adaptation to pain. Engaging in self-care activities suggests that the client is able to maintain independence despite the pain, which is a positive outcome. Choices A, C, and D are incorrect. A decrease in medication use may not always be appropriate for acute pain management. Relaxation techniques can help manage pain but may not be the primary expected outcome. Repeating instructions about medications does not directly relate to the expected outcome of managing acute pain.
Question 2 of 5
The nurse writes the diagnosis"risk for injury related to impaired balance" for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C because assessing for visual acuity and proprioceptive deficits is essential in managing a client with vertigo to identify potential factors contributing to impaired balance. Visual acuity helps determine if vision issues are exacerbating vertigo symptoms, while proprioceptive deficits affect body awareness and balance. By assessing these factors, the nurse can tailor interventions to address specific needs, such as recommending corrective measures for vision problems or implementing balance exercises. A: Providing information about vertigo is important but does not directly address the specific issue of assessing visual acuity and proprioceptive deficits. B: Assessing for diversional activities is important for overall client well-being but does not directly address the balance issues related to vertigo. D: Referring the client to a support group and counseling may be beneficial for emotional support but does not directly address the physical factors contributing to impaired balance.
Question 3 of 5
The home health nurse is admitting a client diagnosed with cancer of the pancreas. Which information is the most important for the nurse to discuss with the client?
Correct Answer: B
Rationale: The correct answer is B: Ask the client if there is an advance directive. This is important because it ensures that the client's wishes regarding their medical care are known and followed, especially in the case of a serious illness like pancreatic cancer. Discussing food preferences (A) and insurance/Medicare reimbursement (C) are important but not as critical initially. Instructing the client to eat as much as possible (D) may not be appropriate for a client with pancreatic cancer as they may have dietary restrictions.
Question 4 of 5
The nurse is admitting a client to rule out aldosteronism. Which assessment data support the client's diagnosis?
Correct Answer: D
Rationale: The correct answer is D (Blood pressure) because aldosteronism is a condition related to the overproduction of aldosterone hormone by the adrenal glands, leading to high blood pressure. Monitoring blood pressure can help identify hypertension, a key indicator of aldosteronism. Temperature (A), pulse (B), and respirations (C) are not directly related to aldosteronism diagnosis. Blood pressure is crucial as it reflects the effects of aldosterone on fluid and electrolyte balance. Monitoring blood pressure helps to assess the impact of aldosterone excess on the cardiovascular system, making it the most relevant assessment data for ruling out aldosteronism.
Question 5 of 5
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?
Correct Answer: A
Rationale: The correct answer is A because ventricular tachycardia can deteriorate into ventricular fibrillation, a more life-threatening rhythm. Ventricular tachycardia is a precursor to ventricular fibrillation due to the rapid, disorganized electrical activity of the ventricles. This can lead to ineffective pumping of the heart, causing decreased cardiac output and potential cardiac arrest. Choices B, C, and D are incorrect because ventricular tachycardia can be converted to a normal rhythm with prompt intervention such as medications or electrical cardioversion. The sense of impending doom and discomfort described in choices C and D are more commonly associated with other dysrhythmias, such as atrial fibrillation or atrial flutter, rather than ventricular tachycardia.