ATI RN
Pathophysiology Final Exam
1. A nurse is teaching a class about immune deficiencies, and a person from the audience asks which cells are affected by severe combined immune deficiency (SCID) syndrome, and the nurse answers:
- A. B cell deficits
- B. T cell deficits
- C. Complement deficits
- D. B and T cell deficits
Correct answer: D
Rationale: The correct answer is D: B and T cell deficits. Severe combined immune deficiency (SCID) syndrome affects both B and T cells, leading to a severe impairment in the immune system's ability to fight infections. Choice A (B cell deficits) is incorrect because SCID affects not only B cells but also T cells. Choice B (T cell deficits) is incorrect as SCID is characterized by deficits in both B and T cells. Choice C (Complement deficits) is incorrect as SCID primarily involves B and T cell deficiencies rather than complement deficiencies.
2. A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?
- A. You shouldn't worry about that. It's not real.
- B. I don't see any FBI agents, but it sounds like you're feeling frightened.
- C. Let's talk about something else to take your mind off of it.
- D. Why do you think the FBI is watching you?
Correct answer: B
Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.
3. What is the priority nursing action for a patient experiencing an acute asthma attack?
- A. Administer bronchodilators
- B. Administer corticosteroids
- C. Provide supplemental oxygen
- D. Start IV fluids
Correct answer: A
Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.
4. When explaining one of the main differences between narcolepsy and obstructive sleep apnea syndrome, what should the nurse mention?
- A. Symptoms of the two diagnoses are essentially the same, making it difficult to differentiate between them.
- B. People with narcolepsy awaken from a nap feeling rested and replenished.
- C. People with obstructive sleep apnea syndrome can experience temporary paralysis during naps.
- D. Naps are contraindicated for clients with narcolepsy due to their association with catatonia.
Correct answer: B: People with narcolepsy awaken from a nap feeling rested and replenished.
Rationale: Narcolepsy is a sleep disorder characterized by excessive daytime sleepiness and sudden attacks of sleep, while obstructive sleep apnea syndrome involves the obstruction of the upper airway during sleep. One of the main differences is that people with narcolepsy often experience refreshing naps, feeling rested and replenished upon waking, which is not the case for obstructive sleep apnea syndrome. This distinction is important for healthcare providers to understand as it helps differentiate between these two sleep disorders.
5. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose
- A. washes the puncture site using warm water and soap
- B. chooses a puncture site in the center of the finger pad
- C. hangs the arm down for a minute before puncturing the site
- D. says the result of 120 mg indicates good blood sugar control
Correct answer: B
Rationale: The correct answer is B because choosing a puncture site in the center of the finger pad is not recommended for blood glucose monitoring. The recommended sites are the sides of the fingertips. Option A is correct as washing the puncture site using warm water and soap is a good practice. Option C is also correct as hanging the arm down for a minute can help increase blood flow. Option D is incorrect as a blood sugar level of 120 mg/dL may not necessarily indicate good blood sugar control and needs further interpretation.
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