ATI RN
Pathophysiology Final Exam
1. What nursing diagnosis is suggested by the patient's statement regarding taking extra griseofulvin when she thinks her infection is getting worse?
- A. Deficient knowledge related to correct use of griseofulvin
- B. Effective therapeutic regimen management related to symptom identification
- C. Disturbed thought processes related to appropriate use of griseofulvin
- D. Ineffective coping related to self-medication
Correct answer: C
Rationale: The correct answer is C: 'Disturbed thought processes related to appropriate use of griseofulvin.' The patient's statement shows a misunderstanding of the correct use of griseofulvin by taking extra medication when she believes her infection is worsening. This behavior indicates a disturbance in her thought process regarding the appropriate use of the medication. Choice A is incorrect because the issue is not lack of knowledge but rather a misunderstanding leading to inappropriate actions. Choice B is incorrect as the patient's actions do not demonstrate effective management of her therapeutic regimen. Choice D is incorrect as the patient is not engaged in self-medication but rather misinterpreting signals and self-adjusting the prescribed medication.
2. A public health nurse is responsible for the administration of numerous immunizations. Which of the following guidelines regarding anaphylaxis should the nurse adhere to?
- A. The patient should be observed for anaphylaxis for 1 minute after administration.
- B. The patient should be observed for anaphylaxis for 5 minutes after administration.
- C. The patient should be observed for anaphylaxis for 30 minutes after administration.
- D. The patient should be observed for anaphylaxis for 90 minutes after administration.
Correct answer: C
Rationale: The correct answer is C: 'The patient should be observed for anaphylaxis for 30 minutes after administration.' This is because anaphylaxis can occur within minutes of administration of an immunization. By observing the patient for 30 minutes, the nurse can promptly identify and manage any signs of anaphylaxis. Choices A, B, and D are incorrect as they suggest shorter or longer observation periods, which may not be sufficient to detect and respond to anaphylaxis in a timely manner.
3. A 25-year-old woman who works as an air traffic controller presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at the airport. What is the most likely diagnosis?
- A. Migraine headache
- B. Cluster headache
- C. Temporomandibular joint syndrome
- D. Sinus headache
Correct answer: C
Rationale: The most likely diagnosis for the 25-year-old woman who works as an air traffic controller and presents with facial pain and severe headache that sometimes radiates to her neck or ear, aggravated by stress, is Temporomandibular joint syndrome. This syndrome involves pain in the jaw joint and the muscles controlling jaw movement, which can radiate to the surrounding areas like the neck and ear. Stress and clenching of the jaw commonly exacerbate the symptoms. Migraine headache (choice A) typically presents with other symptoms like nausea, sensitivity to light or sound, and can be triggered by various factors, not just stress. Cluster headache (choice B) is characterized by severe, unilateral pain around the eye with associated autonomic symptoms. Sinus headache (choice D) is usually associated with sinus congestion or infection, presenting with facial pressure or pain, often worsened by bending forward.
4. What important information should the nurse provide about the risks associated with tamoxifen (Nolvadex) for a patient with a history of breast cancer?
- A. Tamoxifen may increase the risk of venous thromboembolism.
- B. Tamoxifen may decrease the risk of osteoporosis.
- C. Tamoxifen may cause hot flashes and other menopausal symptoms.
- D. Tamoxifen may cause weight gain and fluid retention.
Correct answer: A
Rationale: The correct answer is A: Tamoxifen may increase the risk of venous thromboembolism. Patients on tamoxifen should be educated about the signs and symptoms of blood clots. Choices B, C, and D are incorrect. Tamoxifen does not decrease the risk of osteoporosis; it may cause hot flashes and other menopausal symptoms, and it may cause weight gain and fluid retention.
5. A patient is administered isoniazid (INH) for tuberculosis. Which of the following adverse effects will result in discontinuation of the medication?
- A. Weight gain
- B. Jaundice
- C. Fever
- D. Arthralgia
Correct answer: B
Rationale: The correct answer is B: Jaundice. Isoniazid (INH) is known to cause hepatotoxicity, which can manifest as jaundice. Jaundice is a serious adverse effect that warrants immediate discontinuation of the medication to prevent further liver damage. Weight gain, fever, and arthralgia are not typically associated with isoniazid use and would not necessitate discontinuation of the medication.
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