ATI RN
ATI Pathophysiology Exam
1. Not realizing that its surface was hot, a woman has quickly withdrawn her hand from the surface of a bowl that she was removing from a microwave. Which phenomena has facilitated the rapid movement of her hand in response to the painful stimulus?
- A. Crossed-extensor reflex
- B. Flexor reflex
- C. Withdrawal reflex
- D. Stretch reflex
Correct answer: C
Rationale: The withdrawal reflex is a protective response that allows a person to quickly remove their hand from a painful stimulus.
2. The nurse is preparing to administer a vaccine to a newborn. Before administering the vaccine, the nurse should
- A. warm the vaccine to room temperature.
- B. gently cleanse the chosen injection site.
- C. check the infant's temperature.
- D. administer the full dose at a single injection site.
Correct answer: C
Rationale: Before administering a vaccine to a newborn, it is essential for the nurse to check the infant's temperature. This is important to ensure that the newborn does not have a fever, which could indicate an underlying infection or illness. Warming the vaccine to room temperature is not necessary and could be harmful. Vigorously massaging the injection site is not recommended as it can cause discomfort and tissue damage. Dividing the dose for administration to three injection sites is not standard practice for vaccine administration to a newborn.
3. A client with diabetes mellitus has just undergone a right, below-the-knee amputation following gangrene infection. A few days after the amputation, the client confides in the nurse that he still feels his right foot. Knowing the pathophysiologic principles behind this, the nurse can:
- A. administer a psychotropic medication to help the client cope with the sensation of his amputated leg.
- B. explain that many amputees have this sensation and that one theory surmises the end of a regenerating nerve becomes trapped in the scar tissue of the amputation site.
- C. call the physician and request an order for a psychological consult.
- D. educate the client that this area has an unusually abnormal increase in sensitivity to sensation but that it will go away with time.
Correct answer: B
Rationale: The correct answer is B. The sensation of feeling the amputated limb is known as phantom limb pain, which is common after amputation. One theory suggests that it occurs because the end of a regenerating nerve becomes trapped in the scar tissue at the amputation site. Administering psychotropic medication (choice A) is not the first-line treatment for phantom limb pain. Requesting a psychological consult (choice C) is premature without first addressing the known pathophysiological basis of phantom limb pain. Educating the client that the sensitivity will go away with time (choice D) is not entirely accurate as phantom limb pain can persist long-term.
4. Why is the administration of benzene hexachloride (Lindane) for the treatment of scabies applied in small quantities?
- A. Excessive applications will lead to central nervous system toxicity.
- B. Excessive applications will cause irritation, rash, and inflammation.
- C. Excessive applications will cause headaches, dizziness, and diarrhea.
- D. Excessive applications will lead to anorexia and cachexia.
Correct answer: A
Rationale: The rationale for instructing the patient to apply benzene hexachloride (Lindane) in small quantities for scabies treatment is that excessive applications can lead to central nervous system toxicity. Lindane is a neurotoxin, and overuse or incorrect application can result in adverse effects on the central nervous system, such as seizures, dizziness, and even death. Choices B, C, and D are incorrect because they do not reflect the specific toxic effects associated with Lindane, which primarily affects the central nervous system rather than causing skin irritation, gastrointestinal symptoms, or metabolic issues.
5. A 35-year-old male has enlarged lymph nodes in the neck and a mediastinal mass. He was diagnosed with Hodgkin lymphoma. Which of the following abnormal cells would the nurse expect to find with this disease?
- A. Merkel cell
- B. Schwann cell
- C. Reed-Sternberg cell
- D. Kupffer cell
Correct answer: C
Rationale: Reed-Sternberg cells are characteristic of Hodgkin lymphoma. These large abnormal cells have a bi-lobed or multi-lobed nucleus and are essential for diagnosing Hodgkin lymphoma through histological examination. Merkel cells are associated with Merkel cell carcinoma, Schwann cells are related to nerve sheaths, and Kupffer cells are liver macrophages. Therefore, choices A, B, and D are incorrect for Hodgkin lymphoma.
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