ATI LPN
ATI PN Adult Medical Surgical 2019
1. The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct answer: B
Rationale: Encouraging frequent rest periods is essential in managing hyperthyroidism as it helps address the fatigue and hypermetabolic state commonly associated with this condition. Rest is crucial to support the body's recovery and reduce the stress on the thyroid gland. While nutrition is important in managing hyperthyroidism, providing a high-calorie diet is not the priority intervention. Restricting fluid intake is not typically necessary unless there are specific indications such as heart failure. Administering a stool softener is not directly related to managing hyperthyroidism.
2. The nurse is planning care for a 16-year-old with juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscles. Which physical therapy regimen should the nurse encourage the adolescent to implement?
- A. Exercise in a swimming pool.
- B. Splint affected joints during activity.
- C. Perform passive range of motion exercises twice daily.
- D. Begin a training program of lifting weights and running.
Correct answer: A
Rationale: Exercising in a swimming pool is beneficial for adolescents with juvenile rheumatoid arthritis as it reduces stress on the joints while allowing movement and strengthening. The buoyancy of water supports the body, making exercises easier and less painful, while also providing resistance to strengthen muscles. This form of exercise can help improve joint mobility and overall function without causing excessive strain on the joints. Choices B, C, and D are incorrect because splinting affected joints, performing passive range of motion exercises, or beginning a training program of lifting weights and running can potentially exacerbate symptoms and cause additional stress on the joints, which is not recommended for individuals with juvenile rheumatoid arthritis.
3. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.
4. A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct answer: A
Rationale: The correct response is A: 'The cancer involves only the cervix.' In staging, 'Tis' indicates cancer in situ, which means it is localized to the cervix and not invasive at this time. The differentiation of cancer cells is not part of clinical staging. Since the cancer is in situ, its origin is the cervix. Further testing is not required as the cancer has not spread beyond the cervix. Choice B is incorrect as the staging information provided does not relate to the resemblance of cancer cells to normal cells. Choice C is incorrect because further testing is not necessary as the cancer is localized. Choice D is incorrect because the staging information provided clearly indicates the site of origin as the cervix.
5. During an assessment, a healthcare professional suspects a client has cholecystitis. What is a common symptom of this condition?
- A. Right upper quadrant pain
- B. Left lower quadrant pain
- C. Generalized abdominal pain
- D. Epigastric pain
Correct answer: A
Rationale: Right upper quadrant pain is a hallmark symptom of cholecystitis, indicating inflammation of the gallbladder. The gallbladder is typically located in the right upper quadrant of the abdomen, so pain in this area is characteristic of cholecystitis. This pain may be sharp or cramp-like and can be accompanied by other symptoms such as nausea, vomiting, and fever. Left lower quadrant pain (choice B) is more commonly associated with diverticulitis, generalized abdominal pain (choice C) can be seen in various conditions, and epigastric pain (choice D) is typically related to issues in the upper central part of the abdomen, such as gastritis or peptic ulcers, rather than cholecystitis.
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