a nurse on a postsurgical unit is providing care for a 76 year old female client who is two days post hemiarthroplasty hip replacement and who states

ATI RN

ATI Pathophysiology Final Exam

1. A nurse on a postsurgical unit is providing care for a 76-year-old female client who is two days post-hemiarthroplasty (hip replacement) and who states that her pain has been out of control for the last several hours, though she is not exhibiting signs of pain. Which guideline should the nurse use for short-term and long-term treatment of the client's pain?

A. Pain is what the client says it is, even if she is not exhibiting outward signs.
B. Pain should be treated only when it is associated with observable symptoms.
C. Long-term opioid use is generally safe for elderly clients in a hospital setting.
D. The client's pain should be reassessed after every dose of pain medication.

Correct answer: A

Rationale: Pain is a subjective experience, and the client's report of pain should be taken seriously even if there are no outward signs. Choice B is incorrect because pain can be present without observable symptoms, and waiting for observable signs may delay appropriate pain management. Choice C is incorrect because the safety of long-term opioid use in elderly clients is a complex issue and should be carefully evaluated due to the risk of adverse effects. Choice D is incorrect because while pain reassessment is important, it should not be limited to just after medication administration but should occur regularly to ensure adequate pain control.

2. Which clients are at highest risk for pneumonia?

A. Those in their 20s and 30s and generally healthy
B. Those who exercise regularly and are not exposed to pathogens
C. Those who are hospitalized and immunocompromised
D. Those who have adequate respiratory function

Correct answer: C

Rationale: Clients who are hospitalized and immunocompromised are at the highest risk for pneumonia due to their weakened immune systems. Choice A is incorrect as young and healthy individuals typically have stronger immune systems. Choice B is incorrect because regular exercise can actually boost the immune system and reduce the risk of infections. Choice D is incorrect as having adequate respiratory function does not necessarily correlate with the risk of developing pneumonia.

3. A patient has suffered from several infections in the last 6 months and unexplained impaired wound healing. What assessment should the nurse prioritize?

A. Assess for pain.
B. Assess for nutritional deficiencies.
C. Assess genetic tendency for infection.
D. Assess for edema and decreased hemoglobin.

Correct answer: B

Rationale: In this scenario, the patient's history of multiple infections and impaired wound healing indicates a potential issue with their immune system and overall health. Therefore, the nurse should prioritize assessing for nutritional deficiencies. Proper nutrition is essential for a healthy immune response and wound healing. Assessing for pain (choice A) may be important but addressing the root cause of the recurrent infections and impaired wound healing is crucial. Genetic tendency for infection (choice C) would be a less immediate concern compared to assessing for nutritional deficiencies. Edema and decreased hemoglobin (choice D) are not the most relevant assessments based on the patient's symptoms.

4. A patient with a history of cardiovascular disease is prescribed hormone replacement therapy (HRT). What should the nurse emphasize regarding the long-term risks associated with HRT?

A. HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke.
B. HRT may decrease the risk of osteoporosis.
C. HRT may improve mood and energy levels.
D. HRT may increase the risk of breast cancer.

Correct answer: A

Rationale: HRT is associated with an increased risk of cardiovascular events, including heart attack and stroke, particularly in patients with a history of cardiovascular disease.

5. A patient is prescribed zanamivir (Relenza) to treat influenza B. The patient has a history of asthma. For which of the following symptoms should the nurse assess?

A. Bradycardia
B. Pneumonia
C. Bronchospasm
D. Pulmonary embolism

Correct answer: C

Rationale: The correct answer is C: Bronchospasm. Zanamivir (Relenza) is an inhaled medication used to treat influenza by reducing the severity and duration of symptoms. Patients with a history of asthma are at risk of bronchospasm as a potential side effect of zanamivir. Assessing for bronchospasm is crucial in this case to ensure the patient's safety and well-being. Choices A, B, and D are incorrect. Bradycardia, pneumonia, and pulmonary embolism are not commonly associated with zanamivir use in the treatment of influenza B, especially in a patient with a history of asthma.