ATI RN
Endocrinology Exam
1. When the client finds antiembolism stockings uncomfortably tight, what is the nurse’s best action?
- A. Remove the stockings for an hour to relieve the pressure
- B. Pull the stockings down so that they are not constricting
- C. Measure the client’s calf to ensure that they are the correct size
- D. Teach the client the purpose of wearing the stockings
Correct answer: Teach the client the purpose of wearing the stockings
Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.
2. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Place the client in a negative pressure room.
- B. Wear a surgical mask when entering the client's room.
- C. Place the client in droplet isolation.
- D. Place a surgical mask on the client when transporting them.
Correct answer: A
Rationale: The correct answer is to place the client in a negative pressure room. This action is necessary to prevent the spread of tuberculosis, as it is transmitted via airborne particles. Placing the client in droplet isolation (choice C) is not sufficient for tuberculosis, as it requires airborne precautions. Wearing a surgical mask (choice B) when entering the client's room may not provide adequate protection against airborne transmission. Placing a surgical mask on the client when transporting them (choice D) does not address the need for environmental controls to contain infectious particles.
3. Which statement is not part of the developmental care approach?
- A. Family-centered care
- B. Care on a sliding payment scale
- C. Healing environment
- D. Protected sleep
Correct answer: B
Rationale: The developmental care approach emphasizes creating an environment that supports the infant's developmental needs, including family-centered care, a healing environment, and promoting protected sleep. Payment scale considerations are not a component of developmental care.
4. A 25-year-old woman who works as an air traffic controller presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at the airport. What is the most likely diagnosis?
- A. Migraine headache
- B. Cluster headache
- C. Temporomandibular joint syndrome
- D. Sinus headache
Correct answer: C
Rationale: The most likely diagnosis for the 25-year-old woman who works as an air traffic controller and presents with facial pain and severe headache that sometimes radiates to her neck or ear, aggravated by stress, is Temporomandibular joint syndrome. This syndrome involves pain in the jaw joint and the muscles controlling jaw movement, which can radiate to the surrounding areas like the neck and ear. Stress and clenching of the jaw commonly exacerbate the symptoms. Migraine headache (choice A) typically presents with other symptoms like nausea, sensitivity to light or sound, and can be triggered by various factors, not just stress. Cluster headache (choice B) is characterized by severe, unilateral pain around the eye with associated autonomic symptoms. Sinus headache (choice D) is usually associated with sinus congestion or infection, presenting with facial pressure or pain, often worsened by bending forward.
5. A patient is to be administered an immunization. The serum contains aluminum phosphate. What route is most appropriate to administer this immunization?
- A. Intramuscularly
- B. Subcutaneously
- C. Intravenously
- D. Orally
Correct answer: A
Rationale: The most appropriate route to administer an immunization containing aluminum phosphate is intramuscularly. Aluminum phosphate is commonly used as an adjuvant in vaccines to enhance the immune response. Intramuscular administration allows for the vaccine to be delivered into the muscle tissue, where it can be effectively absorbed by the body's immune cells. Subcutaneous administration is not ideal for vaccines containing aluminum phosphate, as it may not elicit the desired immune response. Intravenous administration is typically reserved for specific medications or situations that require rapid absorption into the bloodstream. Oral administration is not suitable for vaccines containing aluminum phosphate as they would be degraded in the gastrointestinal tract.
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