ATI RN
ATI Pathophysiology Exam 2
1. A 21-year-old female was recently diagnosed with iron deficiency anemia. In addition to fatigue and weakness, which of the following clinical signs and symptoms would she most likely exhibit?
- A. Hyperactivity
- B. Spoon-shaped nails
- C. Gait problems
- D. Petechiae
Correct answer: B
Rationale: The correct answer is B: Spoon-shaped nails. In iron deficiency anemia, spoon-shaped nails (koilonychia) are a common symptom due to changes in the nail bed. This condition is known as Plummer-Vinson syndrome. While fatigue and weakness are common in iron deficiency anemia, hyperactivity (choice A) is not typically associated with this condition. Gait problems (choice C) and petechiae (choice D) are more commonly seen in other medical conditions and are not characteristic of iron deficiency anemia.
2. A nurse is assigned to care for a client with unstable blood pressure. What should the nurse do first?
- A. Monitor the client every two hours.
- B. Continuously monitor the client's vital signs.
- C. Wait for the healthcare provider to provide instructions.
- D. Ask the healthcare provider for specific instructions.
Correct answer: B
Rationale: In the case of a client with unstable blood pressure, the priority action for the nurse is to continuously monitor the client's vital signs. This allows for immediate detection of any fluctuations in blood pressure and timely intervention if necessary. Choice A, monitoring every two hours, may not provide real-time information needed for prompt intervention. Choices C and D suggest waiting for instructions from the healthcare provider, which could cause a delay in addressing the unstable blood pressure, potentially leading to adverse outcomes. Therefore, the most appropriate initial action is to continuously monitor the client's vital signs.
3. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?
- A. Administer sublingual nitroglycerin every 5 minutes
- B. Administer aspirin 325 mg
- C. Encourage the client to use deep breathing exercises
- D. Apply oxygen at 2 L/min via nasal cannula
Correct answer: A
Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.
4. What is a common factor related to all forms of heart failure?
- A. Peripheral edema
- B. Pulmonary edema
- C. Reduced cardiac output
- D. Jugular vein distention
Correct answer: C
Rationale: The correct answer is C: Reduced cardiac output. All forms of heart failure share this common factor, which occurs when the heart is unable to pump enough blood to meet the body's needs. Choices A, B, and D are incorrect. While peripheral edema and pulmonary edema can be symptoms of heart failure, they are not universal to all forms. Jugular vein distention is a sign of right heart failure, not a common factor across all types of heart failure.
5. A nurse is evaluating the effectiveness of teaching regarding care of a child with minimal change nephrotic syndrome (MCNS) that is in remission after administration of prednisone. The nurse realizes further teaching is required if the parents state what?
- A. We will keep our child away from anyone who is ill.
- B. We will be sure to administer the prednisone as ordered.
- C. We will encourage our child to eat a balanced diet, but we will watch his salt intake.
- D. We understand our child will not be able to attend school, so we will arrange for home schooling.
Correct answer: D
Rationale: Children with MCNS in remission can usually return to school. Home schooling may be necessary only if there are complications. The other options show an understanding of proper care during remission.
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