ATI RN
ATI Community Health Nursing Ch 7
1. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client’s significant other?
- A. Awaken the client every two (2) hours.
- B. Monitor for increased intracranial pressure.
- C. Observe frequently for hypervigilance.
- D. Offer the client food every three (3) to four (4) hours.
Correct answer: Awaken the client every two (2) hours.
Rationale: In a client with a mild concussion, it is important to monitor for signs of deterioration, which includes changes in the client's level of consciousness. Waking the client every two hours helps in assessing their neurological status, ensuring they can awaken and respond appropriately. This intervention aids in detecting any worsening symptoms promptly and seeking medical assistance if needed.
2. A toddler is being admitted to the hospital after an Acetaminophen overdose. Which of the following medications should the nurse anticipate administering to this patient?
- A. Acetylcysteine
- B. Pegfilgrastim
- C. Misoprostol
- D. Naltrexone
Correct answer: A
Rationale: In cases of Acetaminophen overdose, acetylcysteine is the antidote of choice. Acetylcysteine helps prevent liver damage by replenishing depleted glutathione levels, which is essential for detoxifying acetaminophen metabolites. Pegfilgrastim is a medication used to stimulate white blood cell production, Misoprostol is a medication for preventing stomach ulcers, and Naltrexone is used for treating opioid addiction and alcoholism, but none of these are indicated for Acetaminophen overdose.
3. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?
- A. At first, the stoma may bleed slightly when touched.
- B. The stoma should appear dark and have a bluish hue.
- C. A burning sensation under the stoma faceplate is normal.
- D. The stoma should remain swollen away from the abdomen.
Correct answer: A
Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.
4. What medication class can decrease tissue inflammation but delays bone healing?
- A. Anticoagulants
- B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Opioids
- D. Narcotics
Correct answer: B
Rationale: The correct answer is B: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are known to decrease tissue inflammation but may delay bone healing. Anticoagulants (Choice A) are used to prevent blood clotting, opioids (Choice C) are pain relievers, and narcotics (Choice D) are drugs that affect the central nervous system. While all the choices may have their own indications and uses in healthcare, NSAIDs are specifically associated with delaying bone healing despite their anti-inflammatory properties.
5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
- A. provide a diet high in vitamin K
- B. alternate periods of rest and activity
- C. teach the patient how to avoid injury
- D. place the patient on protective isolation
Correct answer: B
Rationale: In severe hemolytic anemia, the priority nursing intervention is to alternate periods of rest and activity. This approach helps to balance activity levels to prevent excessive fatigue while promoting mobility and preventing complications such as muscle weakness or deconditioning. Providing a diet high in vitamin K (choice A) is not directly related to managing hemolytic anemia. Teaching the patient how to avoid injury (choice C) is important but may not be the immediate priority. Placing the patient on protective isolation (choice D) is not indicated for hemolytic anemia, as it is not a contagious condition.
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