ATI RN
Final Exam Pathophysiology
1. A client with Guillain-Barré syndrome is experiencing ascending paralysis. Which of the following interventions should the nurse prioritize?
- A. Monitor for signs of respiratory distress.
- B. Prepare the client for plasmapheresis.
- C. Administer analgesics for pain management.
- D. Initiate passive range-of-motion exercises.
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of respiratory distress. In Guillain-Barré syndrome, ascending paralysis can lead to respiratory muscle involvement, putting the client at risk for respiratory distress and failure. Prioritizing respiratory monitoring is crucial to ensure timely intervention if respiratory compromise occurs. Plasmapheresis (Choice B) may be indicated in some cases to remove harmful antibodies, but the priority in this situation is respiratory support. Administering analgesics (Choice C) for pain management and initiating passive range-of-motion exercises (Choice D) are important aspects of care but are not the priority when the client's respiratory status is at risk.
2. A nurse enters a client's room and sees smoke coming from the trash can. What action should the nurse take first?
- A. Call for assistance
- B. Evacuate the room
- C. Attempt to put out the fire
- D. Turn off the oxygen supply
Correct answer: B
Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.
3. While making rounds, the nurse observes the following client behaviors. Which child should the nurse further evaluate for postoperative pain?
- A. The 6-month-old in deep sleep
- B. The 2-year-old who is cooperative when the nurse takes vital signs
- C. The 4-year-old who is actively watching cartoons
- D. The 14-month-old who is screaming and thrashing his arms and legs
Correct answer: D
Rationale: The correct answer is D because screaming and thrashing his arms and legs are indicative behaviors of discomfort or pain in young children. The child's actions suggest a higher likelihood of experiencing postoperative pain and necessitate further evaluation. Choices A, B, and C do not exhibit overt signs of distress or discomfort associated with pain, making them less likely candidates for postoperative pain assessment.
4. Selye's stress theory explains that a person stressed for long periods of time will:
- A. Face exhaustion and be more susceptible to illnesses.
- B. Become fatigued and become stronger.
- C. Become more assertive.
- D. Safety needs.
Correct answer: A
Rationale: Selye's stress theory posits that individuals experiencing prolonged stress are likely to face exhaustion and become more susceptible to illnesses. This is because the body's response to chronic stress can lead to physical and psychological depletion, increasing the risk of health problems. Choice B is incorrect as becoming stronger is not a typical outcome of prolonged stress according to Selye's theory. Choice C, becoming more assertive, is not directly related to the physical implications of chronic stress. Choice D, safety needs, is unrelated to Selye's stress theory and does not reflect the expected outcomes of prolonged stress.
5. A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?
- A. The client is able to ambulate in the hall without dyspnea.
- B. The client has a respiratory rate of 24 breaths per minute.
- C. The client's oxygen saturation is 92%.
- D. The client has a productive cough.
Correct answer: A
Rationale: The correct answer is A. Effective oxygen therapy should improve the client's ability to perform activities without dyspnea. This indicates that the oxygen therapy is adequately supporting the client's respiratory needs. An oxygen saturation of 92% may suggest the need for a higher flow rate to improve oxygenation. A respiratory rate of 24 breaths per minute is elevated, indicating potential respiratory distress. A productive cough does not necessarily indicate effective oxygen therapy, as it is a symptom of respiratory irritation or infection, not oxygenation status.
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