ATI RN
Physical Exam Cardiovascular System
1. The client on nitroglycerin complains of a headache. How does the nurse explain this?
- A. This is a normal side effect of nitroglycerin.
- B. This is an allergic reaction to nitroglycerin.
- C. This is an indication of overdose.
- D. This is a sign of heart failure.
Correct answer: A
Rationale: The correct answer is A: 'This is a normal side effect of nitroglycerin.' Headaches are a common side effect of nitroglycerin due to vasodilation. Choice B is incorrect because allergic reactions to nitroglycerin typically present with symptoms like rash, itching, or shortness of breath. Choice C is incorrect as an overdose of nitroglycerin would likely present with symptoms beyond just a headache. Choice D is incorrect because headaches related to nitroglycerin are not indicative of heart failure.
2. What is considered an acceptable LDL cholesterol level for children and adolescents?
- A. Less than 70 mg/dL
- B. Less than 110 mg/dL
- C. Less than 129 mg/dL
- D. Less than 170 mg/dL
Correct answer: B
Rationale: An LDL cholesterol level of less than 110 mg/dL is considered acceptable and healthy for children and adolescents. This level helps reduce the risk of cardiovascular diseases. Choices A, C, and D are incorrect because an LDL cholesterol level below 110 mg/dL is the recommended target for children and adolescents to maintain good heart health.
3. The staff nurse delegates AM care for two patients to the UAP (Unlicensed Assistive Person). What principle of delegation is the nurse following?
- A. Delegation requires a situation with clearly defined superiors.
- B. Delegation can only exist with a subordinate.
- C. Delegation is a tool used by various healthcare professionals.
- D. You can delegate only those tasks.
Correct answer: D
Rationale: The correct answer is D: 'You can delegate only those tasks.' Delegation in nursing involves transferring responsibility for the performance of a task while retaining accountability for the outcome. The principle of delegation does not require a situation with clearly defined superiors (choice A). Delegation can exist not only with a subordinate but also with colleagues or other healthcare team members (choice B). Delegation is not exclusive to nurses and is a tool used by various healthcare professionals (choice C). Therefore, the best choice is D as it accurately reflects the principle of delegation in nursing.
4. A client is unconscious with a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
- A. Kussmaul respirations
- B. Apneustic respirations
- C. Cheyne-Stokes respirations
- D. Stridor
Correct answer: Cheyne-Stokes respirations
Rationale: Cheyne-Stokes respirations are characterized by periods of deep, rapid breathing followed by periods of apnea. This pattern is often seen in clients with neurological or cardiac conditions. Kussmaul respirations are deep and rapid breaths often associated with metabolic acidosis. Apneustic respirations are characterized by prolonged inhalations with shortened exhalations and can indicate damage to the pons. Stridor is a high-pitched, noisy respiratory sound usually associated with upper airway obstruction. Therefore, in this scenario, the client's alternating pattern of hyperventilation and apnea aligns with Cheyne-Stokes respirations.
5. How do activity observation and analysis support pediatric occupational therapy intervention?
- A. Grading is based on standard protocols for the specific activity.
- B. Preparatory activities are selected to efficiently build specific skills without the need for further design considerations.
- C. Activity synthesis integrates the results to identify alternate ways of performing activities.
- D. Usual modifications for the identified activity are implemented.
Correct answer: C
Rationale: Activity observation and analysis support pediatric occupational therapy intervention by synthesizing information obtained through observation to identify alternative methods of performing activities. This process assists in intervention planning by exploring different approaches to help children achieve their occupational therapy goals effectively.
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