ATI RN
ATI Pathophysiology Exam 2
1. When a client has their 'fight or flight' system activated, which below is a manifestation of that?
- A. Decreased blood pressure
- B. Decreased heart rate
- C. Decreased respiration rate
- D. Increased glucose levels
Correct answer: D
Rationale: The correct answer is D, 'Increased glucose levels.' When the 'fight or flight' system is activated, the body releases glucose to provide energy for the impending response. This increase in glucose levels helps fuel the body's reaction to the perceived threat or stressor. Choices A, B, and C are incorrect because during the 'fight or flight' response, blood pressure, heart rate, and respiration rate typically increase to prepare the body to confront or flee from the perceived danger.
2. What is an appropriate play activity for a 7-month-old infant to encourage visual stimulation?
- A. Playing peek-a-boo
- B. Playing pat-a-cake
- C. Imitating animal sounds
- D. Showing how to clap hands
Correct answer: A
Rationale: Playing peek-a-boo is an ideal play activity for a 7-month-old as it encourages visual tracking and social interaction, which are key developmental milestones at this age.
3. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30 degrees.
- B. Check gastric residual volumes every 4 hours.
- C. Administer the feeding at room temperature.
- D. Flush the feeding tube with 20 mL of water every 8 hours.
Correct answer: B
Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.
4. A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention?
- A. Reassure the mother that this is normal at this age
- B. Recommend the mother substitute a pacifier for her thumb
- C. Assess the infant for other signs of sensory deprivation
- D. Suggest the mother breastfeed the infant more often to satisfy her sucking needs
Correct answer: A
Rationale: Thumb sucking is a normal self-soothing behavior in infants and usually does not indicate a problem. Reassuring the mother that this is normal is the appropriate response.
5. The client is admitted to the hospital with viral hepatitis, complaining of 'no appetite' and 'losing my taste for food.' To provide adequate nutrition, the nurse would instruct the client to
- A. Eat a good supper when anorexia is not as severe.
- B. Eat less often, preferably only three large meals daily.
- C. Increase intake of fluids including juices.
- D. Select foods high in fat.
Correct answer: C
Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a diet with low-fat content because fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may prevent nausea. Appetite is often better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL per day that includes nutritional juices is also important.
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