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ATI Adult Medical Surgical
1. A patient with hyperthyroidism is prescribed propylthiouracil (PTU). What is the primary purpose of this medication?
- A. Increase thyroid hormone production
- B. Suppress thyroid hormone production
- C. Enhance iodine absorption
- D. Stimulate the thyroid gland
Correct answer: B
Rationale: Propylthiouracil (PTU) is a medication used to treat hyperthyroidism by suppressing the production of thyroid hormones. It works by inhibiting the enzyme responsible for the synthesis of thyroid hormones, thereby reducing their levels in the body. This helps to alleviate the symptoms of hyperthyroidism and restore thyroid hormone levels to normal range.
2. A client with liver cirrhosis is being educated about managing their condition. Which statement by the client indicates a need for further teaching?
- A. I will avoid drinking alcohol
- B. I need to limit my salt intake
- C. I can take acetaminophen for pain
- D. I should eat a balanced diet
Correct answer: C
Rationale: The correct answer is C. Clients with liver cirrhosis should avoid acetaminophen because it can cause further liver damage. Acetaminophen is metabolized in the liver, and in individuals with liver disease, it can lead to liver toxicity. Therefore, clients with liver cirrhosis should use alternative pain medications that do not affect the liver, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids as prescribed by their healthcare provider. Choices A, B, and D are correct statements for managing liver cirrhosis. Avoiding alcohol helps prevent further liver damage, limiting salt intake helps manage fluid retention and complications like ascites, and eating a balanced diet supports overall health and helps prevent malnutrition.
3. The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct answer: D
Rationale: The correct action for the nurse to include on the care plan for a patient with a calcium level of 12.1 mg/dL is to encourage fluid intake up to 4000 mL every day. This is essential to decrease the risk for renal calculi associated with hypercalcemia. While bed rest is not necessary, ambulation is encouraged to help decrease the loss of calcium from the bone. Monitoring for Trousseau's and Chvostek's signs is more relevant when hypocalcemia is suspected. Auscultating lung sounds every shift is a routine assessment, not required every 4 hours unless there is a specific respiratory concern.
4. A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?
- A. Encourage them to initiate daily rituals.
- B. Reinforce the reality of their financial situation.
- C. Direct them to drink a glass of red wine at bedtime.
- D. Teach them to limit sugar and caffeine intake.
Correct answer: D
Rationale: Teaching the individual to limit sugar and caffeine intake is an appropriate intervention to reduce anxiety and improve sleep quality. Sugar and caffeine can exacerbate anxiety symptoms and disrupt sleep patterns. By reducing their intake, the individual may experience a decrease in anxiety levels and better sleep. Encouraging daily rituals, reinforcing financial realities, or suggesting alcohol consumption before bed are not evidence-based strategies for managing anxiety and sleeplessness.
5. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.
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