ATI RN
Adult Health Nursing Study Guide Answers Questions
Question 1 of 9
You cannot open Claudia's eyes due to dried crust. Which of the following actions would you do?
Correct Answer: D
Rationale: The best course of action in this scenario is to place a warm wet washcloth over Claudia's eyes for at least three minutes. This will help soften and loosen the dried crust, making it easier to gently clean her eyes and open them. Applying eye drops or ointment may not be effective if the crust is blocking her eyes completely. By using a warm wet washcloth, you can improve the ability to clean her eyes effectively and without causing discomfort.
Question 2 of 9
Which of the following can be a MAJOR PROBLEM for a patient with tracheostomy?
Correct Answer: A
Rationale: Having a tracheostomy means that a patient has an artificial opening in their neck to help them breathe. Therefore, any issues related to breathing, such as blockages in the tracheostomy tube or difficulty in clearing secretions, can pose a major problem for a patient with a tracheostomy. It is crucial to monitor the patient's respiratory status closely and intervene promptly if any breathing difficulties arise to prevent potential respiratory distress or complications.
Question 3 of 9
Which of the following immune cells is primarily responsible for coordinating and regulating immune responses by producing cytokines that direct the activities of other immune cells?
Correct Answer: A
Rationale: T helper cells (Th cells) are primarily responsible for coordinating and regulating immune responses by producing cytokines that direct the activities of other immune cells. These cytokines help in activating cytotoxic T cells, B cells, macrophages, and other cells involved in the immune response. Th cells play a crucial role in mounting an effective immune response against infections and diseases by providing the necessary signals to activate and control various immune cells. Thus, T helper cells are considered the central coordinators of the immune system.
Question 4 of 9
A patient presents with recurrent episodes of fever, sore throat, and cervical lymphadenopathy. Laboratory tests reveal leukocytosis with atypical lymphocytes on peripheral blood smear and positive heterophile antibody test (Monospot test). Which of the following conditions is most likely to cause these findings?
Correct Answer: A
Rationale: The clinical presentation of recurrent fever, sore throat, cervical lymphadenopathy, leukocytosis with atypical lymphocytes, and positive heterophile antibody test (Monospot test) is highly indicative of infectious mononucleosis caused by the Epstein-Barr virus (EBV). EBV is a member of the herpesvirus family and is a common cause of infectious mononucleosis. The atypical lymphocytes seen on peripheral blood smear are reactive T lymphocytes responding to the EBV infection. The Monospot test detects heterophile antibodies produced in response to EBV infection.
Question 5 of 9
Since she wanted to capture the essence and emotion of the victims she chose to use the qualitative design. Which among the statements below is CORRECT about qualitative design?
Correct Answer: C
Rationale: Qualitative research design focuses on gaining an in-depth understanding of attitudes, beliefs, motivations, and behaviors of individuals or groups. It does not typically involve statistical analysis or estimation of relationships between variables like quantitative designs do. Qualitative research involves collecting data through methods such as interviews, observations, or focus groups to provide rich and detailed insights into the experiences and perspectives of the participants. The emphasis is on understanding the meanings individuals attach to their experiences, rather than generalizing findings to a larger population.
Question 6 of 9
A patient with advanced dementia is bedbound and at risk of developing pressure ulcers. What intervention should the palliative nurse prioritize to prevent pressure ulcer formation?
Correct Answer: C
Rationale: The most effective intervention to prevent pressure ulcers in bedbound patients at risk, such as those with advanced dementia, is to use pressure-relieving support surfaces like specialized mattresses or cushions. These surfaces help distribute the pressure evenly, reducing the risk of pressure ulcer formation on bony prominences. Turning the patient every 2 hours (choice A) can also help relieve pressure, but it may not be sufficient to prevent pressure ulcers in high-risk individuals. Applying barrier creams or moisture barriers (choice B) can help protect the skin but may not address the underlying issue of pressure on vulnerable areas. Administering prophylactic antibiotics (choice D) is not recommended for preventing pressure ulcers as it does not address the root cause of the problem and can lead to antibiotic resistance. Therefore, the priority intervention should be to use pressure-relieving support surfaces to minimize the risk of pressure ulcers in
Question 7 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 8 of 9
What PRIORITY precautionary measure should be done by the nurse during the oxygen therapy?
Correct Answer: C
Rationale: Checking the humidifier's water regularly is the priority precautionary measure that should be done by the nurse during oxygen therapy. Maintaining adequate water in the humidifier ensures proper humidification of the oxygen delivered to the patient, helping prevent mucous membrane dryness and irritation. Dry mucous membranes can lead to discomfort, increased risk of infection, and potential damage to the respiratory system. Therefore, ensuring the humidifier's water level is appropriate is crucial for the safety and well-being of the patient receiving oxygen therapy. Limiting visitors, attaching "No Smoking" signage, and connecting the bait to the oxygen tank are important precautions as well, but checking the humidifier's water is the priority measure in this scenario.
Question 9 of 9
The newly hired nurse asks for advice from the supervisor. supervisor notices that the newly hired nurse felt uneasy upon learning that the fetus is on breech presentation. Which of the following is the BEST RESPONSE by the supervisor?
Correct Answer: A
Rationale: The best response by the supervisor is to acknowledge the newly hired nurse's emotions by saying, "I understand how you feel. Tell me more." This response shows empathy and validates the nurse's feelings, creating a supportive environment for open communication. It allows the nurse to express their concerns and fears, leading to a constructive discussion and providing an opportunity for guidance and reassurance. This approach fosters a positive mentorship and learning experience for the newly hired nurse.