ATI RN
ATI Anatomy and Physiology
1. What effect does aldosterone secretion have on electrolyte levels?
- A. Calcium levels are decreased
- B. Sodium levels are increased
- C. Potassium levels are increased
- D. Magnesium levels are decreased
Correct answer: Sodium levels are increased
Rationale: Aldosterone is a hormone that primarily acts on the kidneys to increase the reabsorption of sodium and water into the bloodstream. As a result, sodium levels are increased. Choices A, C, and D are incorrect. Aldosterone does not significantly affect calcium, potassium, or magnesium levels.
2. The nurse is assessing a client with a new diagnosis of Listeria food poisoning. What action should the nurse take first?
- A. Educate the client on safe food practices.
- B. Start a traceback to identify the source of the outbreak.
- C. Report the case to the county board of health.
- D. Ask the client if they have consumed any unpasteurized products.
Correct answer: D
Rationale: The correct first action for the nurse to take when assessing a client with a new diagnosis of Listeria food poisoning is to inquire if the client has consumed any unpasteurized products. This is crucial because Listeria contamination is often associated with unpasteurized dairy products and undercooked meats. Educating the client on safe food practices (Choice A) is important but not the priority at this initial assessment stage. Starting a traceback to identify the source of the outbreak (Choice B) and reporting the case to the county board of health (Choice C) are necessary actions but should come after gathering information directly from the client regarding potential exposure to high-risk foods.
3. What is the most appropriate nursing diagnosis for the client's son based on the information provided?
- A. Risk for other-directed violence
- B. Disturbed sleep pattern
- C. Caregiver role strain
- D. Social isolation
Correct answer: C
Rationale: The correct answer is 'Caregiver role strain.' In the scenario presented, the son expresses that his father's constant confusion, incontinence, and tendency to wander are intolerable. These challenges indicate that the son is experiencing strain in his role as a caregiver. 'Risk for other-directed violence' is not appropriate because there is no indication of violent behavior. 'Disturbed sleep pattern' is not the most relevant nursing diagnosis given the information provided. 'Social isolation' is not the most appropriate choice as the son's concerns are related to the challenges of caregiving, not isolation.
4. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
- A. Place the client's left arm on a pillow while he is sitting.
- B. Provide total care in assisting with the client's ADLs.
- C. Encourage mobility and avoid bed rest.
- D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.
Correct answer: A: Place the client's left arm on a pillow while he is sitting.
Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.
5. Which of the following actions would be of highest priority with regards to the external shunt?
- A. Avoid taking blood pressure or blood sample from the arm with the shunt
- B. Instruct the patient not to exercise the arm with the shunt
- C. Heparinize the shunt daily
- D. Change the dressing of the shunt daily
Correct answer: C: Heparinize the shunt daily
Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.
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