ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with cirrhosis of the liver is experiencing pruritus. Which intervention should the nurse implement to help relieve the client's symptoms?
- A. Administer acetaminophen (Tylenol).
- B. Apply lotion to the skin.
- C. Encourage a high-protein diet.
- D. Provide a warm bath.
Correct answer: B
Rationale: Pruritus is a common symptom in clients with cirrhosis due to bile salts accumulating in the skin. Applying lotion to the skin helps soothe the itching and can prevent skin breakdown. Acetaminophen can worsen liver damage in clients with cirrhosis as it is metabolized in the liver. Encouraging a high-protein diet is not directly related to relieving pruritus. Providing a warm bath may further dry the skin, exacerbating the itching. Therefore, the most appropriate intervention to help relieve pruritus in a client with cirrhosis is to apply lotion to the skin.
2. A patient is being cared for after bariatric surgery, and the healthcare provider is assessing for hemorrhage. What is a sign of hemorrhage?
- A. Increase in blood pressure
- B. Frank red bleeding from the surgical site
- C. Clear drainage from the surgical wound
- D. Decrease in heart rate
Correct answer: B
Rationale: Frank red bleeding from the surgical site is a significant sign of hemorrhage that warrants immediate attention. It indicates active bleeding that needs to be addressed promptly to prevent further complications.
3. The client is prescribed clozapine (Clozaril), and the nurse plans to educate them about its purpose. Which statement should the nurse provide?
- A. It will help you function better in the community.
- B. The medication will help you think more clearly.
- C. You will be able to cope with your symptoms.
- D. It will improve your grooming and hygiene.
Correct answer: B
Rationale: Clozapine (Clozaril) is an antipsychotic medication that is known to improve cognitive function and thought clarity in individuals with schizophrenia. It primarily helps in managing symptoms related to thought processes rather than focusing on community function, coping with symptoms, or grooming and hygiene.
4. A client with a history of atrial fibrillation is prescribed dabigatran (Pradaxa). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to improve absorption.
- B. Avoid foods high in vitamin K.
- C. Take the medication at the same time each day.
- D. Increase your intake of high-potassium foods.
Correct answer: C
Rationale: The correct instruction for the nurse to include in the client's teaching regarding dabigatran (Pradaxa) is to take the medication at the same time each day. This ensures a consistent blood level and effectiveness of the medication, which is crucial in managing atrial fibrillation and preventing complications. It helps maintain a steady therapeutic effect and reduces the risk of erratic drug levels in the body.
5. A 30-year-old woman presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?
- A. Type 1 diabetes mellitus
- B. Type 2 diabetes mellitus
- C. Diabetes insipidus
- D. Hyperthyroidism
Correct answer: A
Rationale: The clinical presentation of a 30-year-old woman with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria is highly suggestive of type 1 diabetes mellitus. Type 1 diabetes mellitus is characterized by autoimmune destruction of pancreatic beta cells, leading to insulin deficiency and subsequent hyperglycemia. The presence of ketonuria indicates the breakdown of fats for energy due to the lack of insulin. In contrast, type 2 diabetes mellitus typically presents with gradual onset and is often associated with insulin resistance rather than absolute insulin deficiency. Diabetes insipidus is characterized by polyuria and polydipsia but is not associated with hyperglycemia or ketonuria. Hyperthyroidism may present with symptoms like fatigue but does not typically cause hyperglycemia or ketonuria.
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