ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?
- A. Intense cold therapy to the extremities
- B. Encourage ultraviolet (UV) light exposure
- C. Administer topical hydrocortisone
- D. Administer antibiotics
Correct answer: Administer topical hydrocortisone
Rationale:
2. A parent brings their 4-year-old child for a check-up. Which finding would concern the nurse?
- A. Ectomorphic body type
- B. Resting pulse rate of 120
- C. Weight gain of 5 lb (2.27 kg) in the past year
- D. No increase in appetite compared with that in toddler years
Correct answer: B
Rationale: A resting pulse rate of 120 is elevated for a 4-year-old and may indicate an underlying issue that needs further investigation. An ectomorphic body type is a body shape and not typically a cause for concern. Weight gain within normal limits and no significant change in appetite are generally positive findings in a growing child.
3. When caring for a patient with systemic lupus erythematosus (SLE), the disease the nurse is dealing with is an example of:
- A. Autoimmunity
- B. Alloimmunity
- C. Homoimmunity
- D. Alleimmunity
Correct answer: A
Rationale: When a nurse cares for a patient with systemic lupus erythematosus (SLE), the nurse is dealing with an autoimmune disease. In autoimmune diseases like SLE, the immune system mistakenly attacks the body's own tissues. Choice A, 'Autoimmunity,' is the correct answer because SLE is an example of the immune system attacking self-antigens, leading to tissue damage and inflammation. Choices B, C, and D are incorrect. Alloimmunity refers to the immune response against foreign antigens from members of the same species, homoimmunity is not a recognized term in immunology, and alleimmunity is not a valid term in this context.
4. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common symptom of this type of cancer?
- A. Dysuria
- B. Hematuria
- C. Urgency on urination
- D. Frequency of urination
Correct answer: B
Rationale: Hematuria, or blood in the urine, is the most common and distinctive symptom associated with bladder cancer. It can present as either gross hematuria (visible blood) or microscopic hematuria (detected only through urinalysis). The presence of blood in the urine often prompts further evaluation for potential underlying causes, including bladder cancer. It is crucial for healthcare providers to recognize this symptom, as early detection significantly impacts treatment outcomes.
5. A client has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. Which of the following instructions should the nurse give the client related to ethambutol?
- A. Your urine can turn a dark orange.
- B. Watch for a change in the sclera of your eyes.
- C. Watch for any changes in vision.
- D. Take vitamin B6 daily.
Correct answer: C: Watch for any changes in vision.
Rationale: Ethambutol is associated with potential vision changes, including optic neuritis. Patients should be instructed to report any visual disturbances immediately to prevent permanent vision loss. Monitoring for changes in vision is crucial to detect any adverse effects early on and prevent serious complications.
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