ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which assessment is NOT a nonverbal sing of pain?
- A. Decreased attention span
- B. Grimacing
- C. Increase in heart rate
- D. Reported pain of 5/10
Correct answer: Reported pain of 5/10
Rationale:
2. A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
- A. Provide high-flow oxygen.
- B. Check the client for a positive Chvostek's sign.
- C. Administer an IV vasopressor medication.
- D. Monitor the client for headache.
Correct answer: Provide high-flow oxygen.
Rationale: In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.
3. A nurse is teaching a group of clients about stress. Which of the following should the nurse include in the teaching?
- A. Protein requirements decrease in times of stress.
- B. Acute stress causes an increase in metabolism.
- C. Stress causes a positive nitrogen balance in the body.
- D. Glucose is broken down more slowly during times of stress.
Correct answer: B
Rationale: The correct answer is B: Acute stress causes an increase in metabolism. During acute stress, the body's fight-or-flight response is activated, leading to an increase in metabolism to provide energy for the body to respond to the stressor. Choices A, C, and D are incorrect. Protein requirements actually increase during times of stress to support the body's needs. Stress typically leads to a negative nitrogen balance in the body, not a positive one. Glucose is broken down more rapidly, not slowly, during times of stress to provide immediate energy.
4. Which medication is used to manage hyperthyroidism?
- A. Levothyroxine
- B. Methimazole
- C. Propylthiouracil
- D. Prednisone
Correct answer: B
Rationale: Methimazole is the correct answer. It is commonly used to manage hyperthyroidism by inhibiting the production of thyroid hormones. Levothyroxine (Choice A) is actually a medication used to treat hypothyroidism by supplementing thyroid hormones. Propylthiouracil (Choice C) is another anti-thyroid medication used in the management of hyperthyroidism. Prednisone (Choice D) is a corticosteroid and is not typically used in the treatment of hyperthyroidism.
5. Which of the following types of cells is primarily responsible for the destruction of old cells and invasive micro-organisms?
- A. Basophils
- B. Eosinophils
- C. B-cells
- D. Macrophages
Correct answer: Macrophages
Rationale: Macrophages are a type of white blood cell that plays a crucial role in the immune system by engulfing and digesting cellular debris, foreign substances, microbes, cancer cells, and old or damaged cells. Basophils are primarily involved in allergic reactions and parasitic infections, eosinophils combat multicellular parasites and have a role in allergic reactions, and B-cells are responsible for producing antibodies. Therefore, the correct answer is macrophages as they are specialized in phagocytosis and removal of unwanted cells and microorganisms.
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