a client is asked to stand with feet together eyes open and hands by the sides then the client is asked to close the eyes while the nurse observes for a client is asked to stand with feet together eyes open and hands by the sides then the client is asked to close the eyes while the nurse observes for
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Nursing Elites

ATI RN

ATI Pathophysiology Exam

1. What assessment is the nurse performing when a client is asked to stand with feet together, eyes open, and hands by the sides, and then asked to close the eyes while the nurse observes for a full minute?

Correct answer: A

Rationale: The correct answer is A, Romberg test. The Romberg test is used to assess balance and proprioception. During the test, the client is asked to stand with feet together, eyes open, and hands by the sides to observe their balance. Then, the client is asked to close their eyes while the nurse continues to observe for a full minute. This test helps in detecting any issues with proprioception and balance, which may be compromised in conditions affecting the nervous system. Choices B, C, and D are incorrect because the Weber test is used to assess hearing in each ear, the Rinne test is used to compare air and bone conduction of sound, and the Babinski test is used to assess the integrity of the corticospinal tract.

2. What is the ability of cardiac cells to generate an electrical impulse without being stimulated by an external source?

Correct answer: A

Rationale: Automaticity is the correct answer because it refers to the inherent ability of cardiac cells to generate electrical impulses without the need for external stimulation. Contractility (Choice B) is the ability of the heart muscle to contract and generate force, not related to electrical impulse generation. Conductivity (Choice C) refers to the ability of cardiac cells to transmit electrical impulses from cell to cell, not the spontaneous generation of impulses. Refractoriness (Choice D) is the period during which the cardiac cells are recovering and not able to respond to a new stimulus, not the spontaneous generation of impulses.

3. A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.

4. Which term refers to high blood pressure, a condition where the force of the blood against the artery walls is too high?

Correct answer: A

Rationale: The correct answer is A, Hypertension. Hypertension is a condition characterized by persistently high blood pressure, which increases the risk of heart disease and stroke. Choice B, Hypotension, refers to low blood pressure. Choice C, Hyperlipidemia, is the term for high levels of fats in the blood. Choice D, Diabetes, is a condition characterized by high blood sugar levels.

5. A client is prescribed diazepam (Valium) for anxiety. Which statement by the client indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A because clients should avoid alcohol while taking diazepam (Valium) due to potential interactions. Alcohol can increase the sedative effects of diazepam, leading to excessive drowsiness or respiratory depression. Choice B is correct as it reflects the need to avoid alcohol. Choice C is incorrect because diazepam is usually taken regularly, not just when feeling anxious. Choice D is incorrect as abruptly stopping diazepam can lead to withdrawal symptoms and should be done gradually under medical supervision.

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