ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. The client with RA complains of intensely dry eyes. What does the nurse suspect?
- A. Systemic sclerosis
- B. Sjogren’s syndrome
- C. Chron’s disease
- D. Discoid lupus
Correct answer: Sjogren’s syndrome
Rationale:
2. An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurse's most appropriate response to the patient's complaint?
- A. Call 911.
- B. Promptly refer the patient for medical assessment.
- C. Facilitate a radiograph of the patient's neck and have the results forwarded to the patient's primary care provider.
- D. Encourage the patient to track the size of the lymph node and seek care in 1 week.
Correct answer: B
Rationale: The most appropriate response for a patient presenting with a firm, painless cervical lymph node and denying recent infectious diseases is to promptly refer the patient for medical assessment. This is crucial to rule out serious underlying conditions such as malignancy or other concerning causes. Calling 911 is not necessary in this situation as it is not an emergency. Ordering a radiograph may not be the most immediate or appropriate action, as further evaluation by a healthcare provider is needed first. Encouraging the patient to wait and track the lymph node for a week is not advisable when a potential serious condition needs to be ruled out promptly.
3. What nursing consideration is most important when caring for a child with end-stage renal disease (ESRD)?
- A. Children with ESRD usually adapt well to minor inconveniences of treatment.
- B. Children with ESRD require extensive support until they outgrow the condition.
- C. Multiple stresses are placed on children with ESRD and their families until the illness is cured.
- D. Multiple stresses are placed on children with ESRD and their families because children's lives are maintained by drugs and artificial means.
Correct answer: D
Rationale: ESRD places significant stress on both the child and the family due to the ongoing need for dialysis, medications, and lifestyle restrictions, making it important for healthcare providers to offer extensive support and resources to manage these challenges.
4. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?
- A. The client will void a minimum of 30 mL per hour
- B. The client will have elastic skin turgor
- C. The client will have no adventitious breath sounds
- D. The client will have a serum creatinine of 1.4 mg/dL
Correct answer: C
Rationale: The correct answer is C. Absence of adventitious breath sounds indicates that fluid is not accumulating in the lungs, a key outcome in managing fluid volume excess. Choices A, B, and D are incorrect. A client with fluid volume excess may not necessarily void a minimum of 30 mL per hour, have elastic skin turgor, or have a specific serum creatinine level. The absence of adventitious breath sounds is a more direct indicator of managing fluid volume excess.
5. What long-term risks should the nurse discuss with a patient being treated with hormone replacement therapy (HRT) for menopausal symptoms?
- A. HRT may increase the risk of cardiovascular events and breast cancer.
- B. HRT may decrease the risk of osteoporosis.
- C. HRT may improve mood and energy levels.
- D. HRT may increase the risk of venous thromboembolism.
Correct answer: A
Rationale: The correct answer is A. Long-term hormone replacement therapy (HRT) is associated with increased risks of cardiovascular events and breast cancer. These risks should be discussed with the patient to ensure they are aware of the potential adverse effects. Choice B is incorrect because HRT does not decrease the risk of osteoporosis; in fact, it has been linked to an increased risk of this condition. Choice C is incorrect as while HRT may have positive effects on mood and energy levels for some individuals, the focus here is on the long-term risks that need to be addressed. Choice D is incorrect as HRT is indeed associated with an increased risk of venous thromboembolism, but the primary focus of the question is on cardiovascular events and breast cancer.
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