ATI RN
Endocrinology Exam
1. A female client with deteriorating neurologic function states, "I am worried I will not be able to care for my young children."? How does the nurse respond?
- A. "Caring for your children is a priority. You may not want to ask for help, but you have to."?
- B. "Our community has resources that may help you with some household tasks so you have energy to care for your children."?
- C. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?"?
- D. "Give me more information about what worries you, so we can see if we can do something to make adjustments."?
Correct answer: D
Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.
2. When obtaining a client’s vital signs, the nurse assesses a blood pressure of 134/88 mm Hg. What is the nurse’s best intervention?
- A. Call the healthcare provider and report the finding.
- B. Reassess the client’s blood pressure at the next follow-up appointment.
- C. Administer an additional antihypertensive medication to the client.
- D. Teach the client lifestyle modifications to decrease blood pressure.
Correct answer: D
Rationale: The correct answer is to teach the client lifestyle modifications to decrease blood pressure. A blood pressure reading of 134/88 mm Hg falls within the prehypertension range. The initial approach to managing prehypertension involves lifestyle modifications such as dietary changes, exercise, and stress reduction techniques. Calling the healthcare provider without attempting non-pharmacological interventions first is premature. Reassessing blood pressure at the next follow-up appointment may delay necessary interventions. Administering additional antihypertensive medication is not indicated at this stage as lifestyle modifications are the first line of treatment for prehypertension.
3. The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)
- A. Potassium level of 2.8 mEq/L
- B. International normalized ratio (INR) of 4
- C. Prothrombin time (PT) of 30 seconds
- D. Positive pregnancy test
Correct answer: C
Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.
4. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?
- A. Poor left-sided motor control
- B. Paralysis or contractures on the right side
- C. Limited visual perception of the left fields
- D. Unawareness of the existence of her left side
Correct answer: D
Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.
5. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?
- A. Document the observation in the chart.
- B. Measure urine specific gravity and volume.
- C. Assess the pulse and blood pressure.
- D. Assess the client's deep tendon reflexes.
Correct answer: C
Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.
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