ATI LPN
ATI Learning System PN Medical Surgical Final Quizlet
1. What is the most appropriate nursing intervention to help alleviate severe abdominal pain in a patient with acute pancreatitis?
- A. Encourage oral intake of clear fluids with electrolytes.
- B. Place the patient in a semi-Fowler's position.
- C. Administer prescribed opioid analgesics.
- D. Apply a cold pack to the abdomen.
Correct answer: C
Rationale: Administering prescribed opioid analgesics is the most appropriate nursing intervention to alleviate severe abdominal pain in a patient with acute pancreatitis. Opioid analgesics help manage severe pain effectively in such cases. Encouraging oral intake of clear fluids with electrolytes is contraindicated due to the need for pancreatic rest and potential exacerbation of symptoms. Placing the patient in a semi-Fowler's position helps reduce pressure on the abdomen, unlike a supine position that can worsen the pain. Applying a cold pack is not recommended as it can potentially increase discomfort and vasoconstriction in acute pancreatitis.
2. The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
- A. Pain when coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: The correct answer is B: Diminished cough effort. Clients with myasthenia gravis often experience muscle weakness, including respiratory muscles, which can lead to diminished cough effort. This weakness can result in ineffective airway clearance, putting the client at a high risk. Pain when coughing (choice A) is not directly related to the etiology of ineffective airway clearance in myasthenia gravis. While thick, dry secretions (choice C) and excessive inflammation (choice D) can contribute to airway clearance issues, the primary concern in myasthenia gravis is the muscle weakness affecting cough effort.
3. A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct answer: D
Rationale: Seizures in a client with suspected meningitis indicate increased intracranial pressure or other complications requiring immediate intervention. Seizures can lead to further neurological damage and need prompt management to prevent adverse outcomes. Therefore, addressing seizures promptly is crucial in the care of a client with suspected meningitis.
4. A patient with severe anemia is prescribed erythropoietin. What is the primary action of this medication?
- A. Stimulate white blood cell production
- B. Increase platelet count
- C. Promote red blood cell production
- D. Enhance clotting factor production
Correct answer: C
Rationale: Erythropoietin is a hormone that primarily stimulates the bone marrow to produce more red blood cells. By increasing red blood cell production, erythropoietin helps to improve oxygen delivery to tissues, which is essential in managing anemia. Choices A, B, and D are incorrect because erythropoietin specifically targets red blood cell production and does not have a direct effect on white blood cells, platelets, or clotting factors.
5. An 89-year-old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him. What age-related condition is likely to be occurring with this client?
- A. Delirium
- B. Presbyopia
- C. Presbycusis
- D. Cerebral dysfunction
Correct answer: C
Rationale: The correct answer is C, Presbycusis. Presbycusis is age-related hearing loss that often affects the ability to hear high-pitched sounds, making speech appear mumbled. This condition is common in older adults and can lead to difficulties in understanding conversations, as in the case of the client complaining about people whispering and mumbling.
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