ATI RN
Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
While the nurse is taking yhe blood pressure, the patient suddenly stated."They are talking about me!". She was referring to other patients who were waiting for their consultation. Which of the following should be the APPROPRIATE nursing action?
Correct Answer: B
Rationale: The appropriate nursing action in this situation would be to distract the patient's attention. When a patient perceives that others are talking about them, it may indicate feelings of paranoia or anxiety. It's important to help the patient refocus on something else to alleviate their distress. Distracting the patient's attention can help calm them down and allow the blood pressure measurement to proceed smoothly. This approach respects the patient's feelings and helps manage the situation effectively.
Question 2 of 9
Nurse Nora notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. what would be the nurse's FIRST action?
Correct Answer: B
Rationale: Patient's uterine contractions lasting 70 seconds and occurring every 90 seconds signify hyperstimulation, which can be a serious complication associated with oxytocin administration. This may result in decreased uterine perfusion, fetal distress, and other adverse effects. The first action should be to discontinue the oxytocin infusion to prevent further complications and allow the uterus to relax. Observations and assessment should continue to monitor the patient's condition and response after discontinuing the infusion. Giving an emergency bolus of oxytocin or increasing the IV infusion rate would exacerbate the hyperstimulation, and turning the client to her left side and breathing deeply would not address the underlying issue of oxytocin-induced hyperstimulation.
Question 3 of 9
Which of the following clinical manifestations would the nurse expect to find when performing admission assessment?
Correct Answer: D
Rationale: When performing an admission assessment, the nurse should expect to find clinical manifestations that are indicative of a variety of conditions. Paresthesia (abnormal sensation like tingling, prickling, or numbness) and muscle weakness of the upper body are commonly associated with neurological conditions such as peripheral neuropathy or cervical radiculopathy. These symptoms suggest dysfunction in the nerves that supply the upper body muscles, leading to sensory changes and weakness. This finding would prompt further assessment and evaluation by healthcare providers to determine the underlying cause and appropriate interventions. Rapid progressive muscular atrophy, ascending paralysis with ataxia, and hyperactive deep tendon reflexes are not typically expected findings during an admission assessment and may signal more specific neurological conditions such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, or spinal cord injury, respectively.
Question 4 of 9
A postpartum client who delivered vaginally reports difficulty emptying the bladder completely and experiences urinary frequency. What nursing intervention should be prioritized to address this issue?
Correct Answer: A
Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.
Question 5 of 9
Nurse Harper provides health instruction to the patient experiencing heartburn, which statement by the patient indicates a NEED or further Instructions? I have to drink milk between meals it
Correct Answer: A
Rationale: This statement indicates a need for further instructions because drinking milk between meals may worsen heartburn for some individuals. Milk can temporarily neutralize stomach acid, but it can also stimulate acid production in the stomach leading to increased heartburn symptoms. Therefore, Nurse Harper should provide more guidance on appropriate dietary choices for managing heartburn, such as avoiding trigger foods like fatty or spicy foods, eating small, frequent meals, and not lying down immediately after eating.
Question 6 of 9
In this pandemic nurses are float to areas of most need in the time of a nursing shortage, this is an example of:
Correct Answer: A
Rationale: Utilitarianism is an ethical theory that focuses on producing the greatest overall balance of good over bad consequences for everyone involved. In the context of the situation described, nurses being floated to areas of most need during a nursing shortage is an example of utilitarianism in action. The decision to float nurses is aimed at maximizing the benefit to the greatest number of patients by ensuring that critical care is provided where it is most needed, even if it may cause inconvenience or discomfort to the nurses being floated. This decision aligns with the principle of maximizing overall utility and promoting the greater good, which are central tenets of utilitarianism.
Question 7 of 9
In problem solving the head nurse must know what is the MAJOR characteristic of negotiation?
Correct Answer: A
Rationale: The MAJOR characteristic of negotiation is being positive in your approach since optimism typically leads to more favorable results. Negotiation involves communication, compromise, and finding mutually beneficial solutions. Approaching negotiations with a positive mindset can help in maintaining a constructive atmosphere, enhancing communication, and increasing the likelihood of reaching a successful agreement. Being positive can also contribute to building relationships and trust with the other party, leading to better long-term outcomes.
Question 8 of 9
Which of the following is NOT included among the factors that should be considered by the nurse or the pregnant woman in interpreting results of pregnancy test?
Correct Answer: B
Rationale: The type of pregnancy test is not a factor that should be considered by the nurse or the pregnant woman in interpreting the results of a pregnancy test. Factors such as the last menstrual period, previous pregnancy history, and menstrual cycle length play a crucial role in determining the reliability and accuracy of the pregnancy test results.
Question 9 of 9
A nurse is caring for a patient who is experiencing conflicting emotions about a recent diagnosis. What therapeutic communication technique should the nurse use to help the patient explore their feelings?
Correct Answer: C
Rationale: Reflecting the patient's feelings and expressions is a therapeutic communication technique that involves mirroring back the patient's emotions and thoughts. By doing this, the nurse validates the patient's experiences and helps them explore their feelings further. This technique can enhance the patient's self-awareness and promote emotional expression, leading to a deeper understanding of their conflicting emotions. Offering advice (Option A) may not be as effective because the focus should be on helping the patient process their own emotions. Providing reassurance and false hope (Option B) can hinder the patient's emotional exploration and may lead to trust issues if the reality does not align with the false reassurance. Redirecting the conversation to a different topic (Option D) avoids addressing the patient's conflicting emotions, which is crucial for therapeutic communication and support.