ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
A mother brings her children into the clinic and they are diagnosed with chickenpox. The mother had chickenpox as a child and is not concerned with contracting the disease when caring for her children. what type of immunity does this mother have?
Correct Answer: A
Rationale: The correct answer is A: Active natural immunity. The mother had chickenpox as a child, which triggered her immune system to produce antibodies, providing long-lasting protection. This is an example of active immunity because her immune system actively responded to the pathogen. Summary: B: Passive artificial immunity - This involves receiving pre-made antibodies, not produced by the individual's immune system. C: Passive natural immunity - This is acquired through placental transfer or breastfeeding, not through prior exposure to the pathogen. D: Active artificial immunity - This is acquired through vaccination, not through natural exposure to the pathogen.
Question 2 of 5
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.
Question 3 of 5
The nurse encourages a client with an immunologic disorder to eat a nutritionally balanced diet to promote optimal immunologic function. Autoimmunity has been linked to excessive ingestion of:
Correct Answer: C
Rationale: The correct answer is C: Fat. Excessive ingestion of fat has been linked to autoimmunity due to its potential to trigger inflammation in the body, which can disrupt the immune system's balance and lead to autoimmune responses. High-fat diets have been associated with increased production of pro-inflammatory molecules, impacting immune function negatively. Protein (choice A) is essential for immune function, vitamin A (choice B) supports immune responses, and zinc (choice D) is crucial for immune system regulation. However, excessive intake of these nutrients typically does not directly lead to autoimmunity like excessive fat consumption does.
Question 4 of 5
A client hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which of the following instructions would be most important to include in the client�s teaching plan?
Correct Answer: A
Rationale: The correct answer is A: maintain a moderate exercise. Exercise helps in maintaining bone density, which is crucial in managing hyperparathyroidism. Moderate exercise can also help in weight management and overall health. Choice B, losing weight, can be helpful but not as crucial as exercise. Choice C, jogging 2 miles per day, may be excessive for some individuals and not necessary for managing hyperparathyroidism. Choice D, resting as much as possible, is not recommended as it can lead to muscle weakness and bone loss, which are already concerns in hyperparathyroidism.
Question 5 of 5
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient�s plan of care?
Correct Answer: C
Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance. A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit. B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake. D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.
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