ATI RN
Theories of Health Behavior Change Questions
Question 1 of 5
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?
Correct Answer: A
Rationale: Rationale: 1. Platelet count: DIC causes excessive clotting leading to platelet consumption. 2. Prothrombin time (PT): Evaluates the extrinsic pathway of coagulation, prolonged in DIC. 3. Partial thromboplastin time (PTT): Assesses intrinsic pathway, also prolonged in DIC. Therefore, A is correct for monitoring DIC. Summary: B is incorrect because blood glucose and WBC count are not directly related to DIC. C is incorrect as thrombin time, calcium, and potassium levels are not specific to DIC. D is incorrect as fibrinogen level is not included in standard DIC monitoring.
Question 2 of 5
Nurse Ron begins to teach a male client how to perform colostomy irrigations. The nurse would evaluate that the instructions were understood when the client states, "I should:
Correct Answer: B
Rationale: The correct answer is B because keeping the irrigating container less than 18 inches above the stoma helps regulate the flow rate of the solution, preventing discomfort or damage to the stoma. Placing the container too high can cause rapid flow, leading to cramping or leakage. Choices A, C, and D are incorrect. Choice A is incorrect because the client should actually lie on his back, not the left side, to facilitate the irrigation process. Choice C is incorrect as instilling too much solution can cause discomfort or damage to the bowel. Choice D is incorrect because the client should not insert the catheter deeper if cramping occurs, as this could cause injury to the bowel.
Question 3 of 5
Nurse Tristan is caring for a male client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
Correct Answer: C
Rationale: The correct answer is C, hyperkalemia. In acute renal failure, the kidneys are unable to excrete potassium effectively, leading to elevated levels in the blood. Hypertonic glucose with insulin helps shift potassium into the cells, reducing blood levels. Sodium bicarbonate can also help by correcting acidosis, which can worsen hyperkalemia. A: Hypernatremia involves high sodium levels, treated with fluid restriction or diuretics. B: Hypokalemia is low potassium levels, treated with potassium supplementation. D: Hypercalcemia is high calcium levels, treated with hydration and medications to lower calcium levels.
Question 4 of 5
A male client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, Nurse Oliver notes that the client's stoma appears dusky. How should the nurse interpret this finding?
Correct Answer: A
Rationale: The correct answer is A: Blood supply to the stoma has been interrupted. A dusky appearance of the stoma indicates poor blood supply, which can lead to tissue ischemia and necrosis. This is a critical finding that requires immediate intervention to prevent further complications. In contrast, the other options are incorrect. Option B is incorrect because a dusky stoma is not a normal finding post-ileostomy surgery. Option C is incorrect as adjusting the ostomy bag will not address the underlying issue of compromised blood supply. Option D is incorrect as an intestinal obstruction would present with different symptoms and would not cause the stoma to appear dusky.
Question 5 of 5
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?
Correct Answer: C
Rationale: The correct answer is C because calling up the latest electrocardiogram results to check the client's progress breaches the client's confidentiality since this action involves disclosing the client's medical information to someone unauthorized to receive it. This violates the client's right to privacy and confidentiality. A, B, and D are incorrect: A: Giving a verbal report to the nurse on the telemetry unit is appropriate as it facilitates continuity of care and is within the scope of healthcare providers involved in the client's treatment. B: Notifying the on-call physician about a change in the client's condition is also essential for timely medical intervention and does not breach confidentiality. D: Updating the client's wife on his condition at his request is permissible as long as the client consents to sharing his medical information with his spouse.