ATI RN
Pathophysiology Practice Questions
1. Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer’s type and confabulates. The nurse understands that this client:
- A. Denies confusion by being jovial.
- B. Pretends to be someone else.
- C. Rationalizes various behaviors.
- D. Fills in memory gaps with fantasy.
Correct answer: D
Rationale: Confabulation, a common symptom in dementia, involves filling in memory gaps with fabricated stories rather than intentionally pretending to be someone else (Choice B), denying confusion by being jovial (Choice A), or rationalizing various behaviors (Choice C). Confabulation is not a deliberate act but a memory error that results in the creation of false memories.
2. A nurse misreads a glucose level and administers insulin for a blood glucose of 210 mg/dL instead of 120 mg/dL. What is the priority intervention?
- A. Monitor for hypoglycemia
- B. Monitor for hyperkalemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: A
Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.
3. Magnesium's major functions in the body would be least likely to include which of the following?
- A. allowing muscles to relax after contraction
- B. assisting the operation of hundreds of enzymes
- C. synthesis of protein in the soft tissues
- D. regulation of body temperature
Correct answer: D
Rationale: Magnesium plays a key role in muscle relaxation, enzyme operation, and protein synthesis, but it is not directly involved in regulating body temperature.
4. Upon admission, a client diagnosed with major depressive disorder needs the nurse to implement which of the following interventions first?
- A. Administer an antidepressant medication.
- B. Establish a trusting relationship with the client.
- C. Develop a plan of care with the client.
- D. Teach the client about the importance of medication compliance.
Correct answer: B
Rationale: The initial intervention the nurse should prioritize is to establish a trusting relationship with the client. Building trust is fundamental in fostering effective therapeutic communication and providing quality care. This foundational step lays the groundwork for further assessment, collaboration on care plans, and promoting treatment adherence. Administering medication or discussing compliance should come after the establishment of trust to ensure the client feels supported and understood.
5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
- A. Request a renewal of the prescription every 8 hours.
- B. Check the client's peripheral pulse rate every 30 minutes.
- C. Obtain a prescription for restraint within 4 hours.
- D. Document the client's condition every 15 minutes.
Correct answer: C
Rationale: When caring for a client with bipolar disorder experiencing acute mania and having obtained a verbal prescription for restraints, the nurse must ensure to obtain a formal written prescription for restraint within 4 hours. This is crucial to maintain the safety and proper care of the client. Choices A, B, and D are incorrect because renewing the prescription every 8 hours, checking pulse rate every 30 minutes, and documenting the client's condition every 15 minutes do not address the immediate need for a formal restraint prescription within 4 hours to manage the client's acute mania effectively.
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