ATI RN
Endocrinology Exam
1. A female client with deteriorating neurologic function states, “I am worried I will not be able to care for my young children.” How does the nurse respond?
- A. “Caring for your children is a priority. You may not want to ask for help, but you have to.”
- B. “Our community has resources that may help you with some household tasks so you have energy to care for your children.”
- C. “You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?”
- D. “Give me more information about what worries you, so we can see if we can do something to make adjustments.”
Correct answer: “Give me more information about what worries you, so we can see if we can do something to make adjustments.”
Rationale: When a client expresses worry about not being able to care for her children due to deteriorating neurologic function, the most appropriate response from the nurse is to gather more information from the client. This open-ended approach allows the nurse to better understand the client's specific concerns and needs, leading to tailored interventions and support. Choice A is dismissive and may make the client feel guilty for needing help. Choice B focuses on external resources without addressing the client's worries directly. Choice C suggests a psychological referral without exploring the client's concerns further. Therefore, the correct response is to gather more information to provide personalized support.
2. A registered nurse (RN) is caring for a patient who is one of Jehovah�s Witnesses and has refused a blood transfusion even though her hemoglobin is dangerously low. After providing information about all the alternatives available and risks and benefits of each, the health-care provider allows the patient to determine which course of treatment she would prefer. The RN knows this is an example of which ethical principle?
- A. Autonomy
- B. Nonmaleficence
- C. Beneficence
- D. Distributive justice
Correct answer: A
Rationale: This is an example of the ethical principle of autonomy.
3. A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?
- A. Holding the newborn in an en face position
- B. Asking the father to change the newborn's diaper
- C. Requesting the nurse to take the newborn to the nursery so she can rest
- D. Viewing the newborn's actions as uncooperative
Correct answer: D
Rationale: The correct answer is D because viewing the newborn's actions as uncooperative indicates a lack of bonding, which requires intervention. Choices A, B, and C all involve appropriate and caring actions by the client towards the newborn. Holding the newborn in an en face position promotes bonding, involving the father in caring for the newborn is beneficial for family involvement, and requesting rest by asking the nurse to take the newborn to the nursery is a responsible action to ensure both the client and the newborn get adequate rest.
4. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?
- A. Insert an indwelling urinary catheter
- B. Apply fetal heart rate monitor
- C. Initiate fundal massage
- D. Initiate an oxytocin IV infusion
Correct answer: B
Rationale: Applying a fetal heart rate monitor is the priority action in this scenario as it helps assess the well-being of the fetus during labor. This monitoring is crucial to detect any signs of fetal distress and guide interventions. Inserting an indwelling urinary catheter (Choice A) is not a priority at this time unless there are specific indications. Initiating fundal massage (Choice C) is not necessary in this situation as the focus should be on fetal assessment. Initiating an oxytocin IV infusion (Choice D) is not indicated until the stage of labor and the progress of labor are determined.
5. The nurse has inserted a nasogastric tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts slowly to advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation?
- A. Continuing to advance the tube to the desired distance
- B. Pulling the tube back slightly
- C. Checking the back of the pharynx using a tongue blade and flashlight.
- D. Instructing the client to breathe slowly and take sips of water.
Correct answer: A
Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax to reduce the gag response. The nurse should check the back of the client’s throat to note if the tube has coiled. The tube may be advanced after the client relaxes.
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