which question should the nurse ask when assessing the client for an endocrine dysfunction

ATI RN

ATI RN Custom Exams Set 1

1. Which question should the healthcare provider ask when assessing the client for an endocrine dysfunction?

A. “Have you noticed any pain in your legs when walking?”
B. “Have you had any unexplained weight loss?”
C. “Have you noticed any change in your bowel movements?”
D. “Have you experienced any joint pain or discomfort?”

Correct answer: B

Rationale: The correct answer is B: “Have you had any unexplained weight loss?” Unexplained weight loss can be a significant symptom of various endocrine disorders, such as hyperthyroidism and diabetes. Weight changes are often closely linked to endocrine dysfunction due to the hormonal imbalances affecting metabolism. Choices A, C, and D are less specific to endocrine dysfunction. Pain in the legs, changes in bowel movements, and joint pain or discomfort are symptoms that can be related to various health conditions but are not as indicative of endocrine disorders as unexplained weight loss.

2. For which client situation would a consultation with a rapid response team (RRT) be most appropriate?

A. 45-year-old; 2 years post kidney transplant; second hospital day for treatment of pneumonia; no urine output for 6 hours; temperature 101.4°F; heart rate of 98 beats per minute; respirations 20 breaths per minute; blood pressure 88/72 mm Hg; is restless
B. 72-year-old; 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion); temperature 97.8°F; heart rate 92 beats per minute; respirations 28 breaths per minute; blood pressure 132/86 mm Hg; anxious about going home
C. 56-year-old fourth hospital day after coronary artery bypass procedure; sore chest; pain with walking temperature 97°F; heart rate 84 beats per minute; respirations 22 breaths per minute; blood pressure 87/72 mm Hg; bored with hospitalization
D. 86-year-old; 48 hours postoperative repair of fractured hip (nail inserted; alert; oriented; using patient-controlled analgesia (PCA) pump; temperature 96.8°F; heart rate 60 beats per minute; respirations 16 breaths per minute; blood pressure 90/62 mm Hg; talking with daughter

Correct answer: A

Rationale: The correct answer is A. This client situation presents with concerning clinical signs such as no urine output post kidney transplant, elevated temperature, tachycardia, hypotension, and restlessness, suggestive of acute renal failure and sepsis. These signs necessitate immediate intervention by the rapid response team (RRT) to address the potentially life-threatening conditions. Choice B is incorrect as the client is stable after chest tube removal and primarily anxious about going home. Choice C is incorrect as the client's symptoms are related to postoperative recovery and boredom, not indicating an urgent need for RRT consultation. Choice D is incorrect as the client post hip repair is stable, alert, and interacting normally, without signs of acute deterioration requiring RRT involvement.

3. In which situation(s) does the nurse act as a client advocate?

A. Pulling the curtain around the client’s bed while changing a dressing
B. Contacting the health care provider to request a meeting for the client
C. Ensuring access to medical information by appropriate personnel only
D. All of the above

Correct answer: D

Rationale: The correct answer is D because all the situations listed reflect aspects of client advocacy. Pulling the curtain around the client's bed while changing a dressing ensures privacy and dignity for the client, which is an essential part of advocacy. Contacting the health care provider to request a meeting for the client involves advocating for the client's needs and preferences. Ensuring access to medical information by appropriate personnel only is another way the nurse advocates for the client by safeguarding their confidentiality and promoting proper communication. Choices A, B, and C all demonstrate different aspects of advocacy, making option D the correct choice.

4. Identifying the strengths and weaknesses in the plan of nursing care is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

A. Evaluation
B. Planning
C. Implementation
D. Assessment

Correct answer: A

Rationale: The correct answer is A: Evaluation. Evaluation in nursing care involves assessing the effectiveness of the care plan, identifying strengths, weaknesses, and areas for improvement. This step helps ensure that the patient's needs are being met appropriately. Planning (choice B) involves developing the care plan based on the assessment data. Implementation (choice C) is the step where the care plan is put into action. Assessment (choice D) is the initial step in the nursing process that involves collecting and analyzing data about the patient's health status.

5. A patient with a history of gout should avoid which type of food?

A. Red meat
B. Chicken
C. Fish
D. Dairy

Correct answer: A

Rationale: The correct answer is A: Red meat. Red meat is high in purines, which can exacerbate gout attacks. Gout is a form of arthritis that occurs when high levels of uric acid in the blood lead to the formation of urate crystals in the joints. Purine-rich foods can increase uric acid levels, leading to gout symptoms. Chicken and fish are lower in purines compared to red meat, making them better choices for individuals with gout. Dairy products are generally considered safe for gout patients and may even have a protective effect against gout.