ATI RN
Pathophysiology Exam 1 Quizlet
1. A nurse is caring for a client with a newly inserted pacemaker. What is the most important nursing action post-procedure?
- A. Monitor the insertion site for signs of infection.
- B. Educate the client about activity restrictions.
- C. Monitor the client's heart rate and rhythm.
- D. Assess the client's lung sounds for signs of fluid overload.
Correct answer: A
Rationale: Post-procedure, monitoring the insertion site for signs of infection is crucial because it helps in early detection of any potential complications such as infection. While educating the client about activity restrictions, monitoring the client's heart rate and rhythm, and assessing lung sounds for signs of fluid overload are important aspects of care, the immediate priority post-procedure is to prevent infection at the insertion site, which could lead to serious complications.
2. When assessing for potential signs and symptoms of cryptococcosis in a patient with HIV being treated with Amphotericin B, the nurse should prioritize what assessment?
- A. Neurological assessment
- B. Functional assessment
- C. Nutritional assessment
- D. Cardiac assessment
Correct answer: A
Rationale: In a patient with cryptococcosis and HIV, neurological assessment should be prioritized because cryptococcosis commonly affects the central nervous system, leading to symptoms such as headache, confusion, and altered mental status. This assessment is crucial in monitoring for any neurological complications and guiding appropriate interventions. Functional assessment focuses on the patient's ability to perform activities of daily living and is not directly associated with cryptococcosis. Nutritional assessment is important for overall health but is not the priority when assessing for cryptococcosis. Cardiac assessment is not a priority in cryptococcosis as the primary manifestations are related to the central nervous system.
3. A patient with a history of breast cancer is prescribed tamoxifen (Nolvadex). What critical information should the nurse include in the patient education?
- A. Tamoxifen may increase the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots.
- B. Tamoxifen may cause weight gain, so patients should monitor their diet.
- C. Tamoxifen may decrease the risk of osteoporosis, so patients should ensure adequate calcium intake.
- D. Tamoxifen may cause hot flashes and other menopausal symptoms.
Correct answer: A
Rationale: Tamoxifen increases the risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots and the importance of seeking immediate medical attention if they occur.
4. A nurse practitioner is assessing a 7-year-old boy who has been brought to the clinic by his mother, who is concerned about her son's increasingly frequent, severe headaches. Which of the nurse's questions is least likely to yield data that will confirm or rule out migraines as the cause of his problem?
- A. Does your son have a family history of migraines?
- B. When your son has a headache, does he ever have nausea and vomiting as well?
- C. Does your son have any food allergies that have been identified?
- D. Is your son generally pain-free during the intervals between headaches?
Correct answer: C
Rationale: The correct answer is C. In assessing a child for migraines, asking about food allergies is least likely to yield data that will confirm or rule out migraines as the cause of his headaches. Food allergies are unrelated to the typical symptoms and triggers of migraines, such as family history, associated symptoms like nausea and vomiting, and pain-free intervals between headaches. Therefore, in this scenario, focusing on food allergies is less relevant for identifying migraines as the cause of the boy's headaches.
5. When a Tae Kwon Do (TKD) master applies downward pressure just above the elbow joint on an attacker who immediately collapses to the ground, which reflex is applicable to this example?
- A. Golgi tendon reflex
- B. Myotatic reflex
- C. Withdrawal reflex
- D. Crossed-extensor reflex
Correct answer: A
Rationale: The Golgi tendon reflex is the correct answer. This reflex protects the muscle and tendons from excessive force by causing the muscle to relax. In this scenario, the downward pressure applied just above the elbow joint triggers the Golgi tendon reflex, resulting in the attacker's collapse. The other options are incorrect: - The myotatic reflex (also known as the stretch reflex) is responsible for contracting a muscle in response to its stretch, not relaxing it. - The withdrawal reflex is a spinal reflex that moves a body part away from a painful stimulus, not directly related to the scenario described. - The crossed-extensor reflex is a reflex that occurs on the opposite side of the body in response to a withdrawal reflex, which is not the case in this situation.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99