ATI RN
Foundations and Adult Health Nursing Study Guide Answers Questions
Question 1 of 5
If Baby Sharon develops dehydration, what is the FIRST sign to look for by Nurse Juvy?
Correct Answer: B
Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.
Question 2 of 5
A patient presents with muscle weakness, fatigue, constipation, and hyperpigmentation of the skin. Laboratory tests reveal low serum cortisol levels and elevated adrenocorticotropic hormone (ACTH) levels. Which endocrine disorder is most likely responsible for these symptoms?
Correct Answer: D
Rationale: The symptoms described - muscle weakness, fatigue, constipation, hyperpigmentation of the skin, low serum cortisol levels, and elevated ACTH levels - are classic findings in Addison's disease. Addison's disease is a primary adrenal insufficiency characterized by the insufficient production of cortisol and, to some extent, aldosterone. The low cortisol levels result in symptoms such as muscle weakness, fatigue, and skin hyperpigmentation due to increased levels of ACTH stimulating melanin production. In contrast, in conditions like hyperthyroidism, hypothyroidism, and diabetes mellitus, the symptoms and laboratory findings would not fully align with those described in the patient in this scenario.
Question 3 of 5
A pregnant woman presents with severe lower abdominal pain, fever, and vaginal discharge. On examination, cervical motion tenderness and adnexal tenderness are noted, along with bilateral adnexal masses. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: B
Rationale: The constellation of severe lower abdominal pain, fever, and vaginal discharge in a pregnant woman raises suspicion for pelvic inflammatory disease (PID). Cervical motion tenderness and adnexal tenderness are classic physical exam findings for PID. The presence of bilateral adnexal masses further supports the diagnosis, as PID can lead to the formation of tubo-ovarian abscesses. Ectopic pregnancy may present with similar symptoms but is less likely in this case as bilateral adnexal masses suggest a more diffuse inflammatory process. Placenta previa would typically present with painless vaginal bleeding in the third trimester, which is not consistent with the symptoms described. Ovarian torsion would present with sudden severe unilateral lower abdominal pain and is less likely to involve both ovaries simultaneously.
Question 4 of 5
The nurse is aware that a major difference between Hodgkin's lymphoma and non- Hodgkin's lymphoma is that:_________________
Correct Answer: B
Rationale: One of the major differences between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that Hodgkin's lymphoma is considered potentially curable, while non-Hodgkin's lymphoma is typically not curable. Hodgkin's lymphoma is characterized by the presence of Reed-Sternberg cells, which are not found in non-Hodgkin's lymphoma. Additionally, Hodgkin's lymphoma tends to spread in a more orderly and predictable manner through the lymph nodes, making it easier to treat and potentially cure with the appropriate combination of chemotherapy, radiation therapy, and stem cell transplant. On the other hand, non-Hodgkin's lymphoma is a diverse group of lymphomas that can vary greatly in presentation, behavior, and response to treatment, with some subtypes being more aggressive and resistant to treatment. Therefore, the potential for cure is higher in Hodgkin's lymphoma compared to non-Hodgkin's lymph
Question 5 of 5
One evening, Jose complained of dyspnea despite continuous oxygen therapy. What should be the nurse's INITIAL intervention?
Correct Answer: C
Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.
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