Concepts for Nursing Practice 3rd Edition Test Bank

Questions 14

ATI RN

ATI RN Test Bank

Concepts for Nursing Practice 3rd Edition Test Bank Questions

Question 1 of 5

The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the

Correct Answer: A

Rationale: For a 7-year-old client recovering from partial-thickness burns with sensitivity to loud noises and bright lights, along with a tendency to become overstimulated, the best teaching environment would be the client's room. This setting provides a familiar and comforting space where the client feels secure and less exposed to external stimuli that may trigger discomfort or anxiety. Being in her own room allows the client to focus better, feel more at ease, and have better communication with the nurse without distractions from bright lights, loud noises, or other people around. This controlled and peaceful environment contributes to a more effective teaching and learning experience for the client, promoting better understanding and retention of information.

Question 2 of 5

The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?

Correct Answer: A

Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.

Question 3 of 5

After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?

Correct Answer: B

Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.

Question 4 of 5

A client with sepsis has a temperature of 40�C. Which dysrhythmia is most likely to occur in this client?

Correct Answer: B

Rationale: A client with sepsis and a temperature of 40�C is likely experiencing a systemic inflammatory response, which can lead to a variety of dysrhythmias. In this case, the client is more likely to develop a tachydysrhythmia (fast heart rate) due to the body's response to the infection. Sepsis can result in an increase in heart rate as the body tries to maintain adequate perfusion to vital organs in response to the inflammatory process. Tachydysrhythmias such as supraventricular tachycardia or atrial fibrillation are commonly observed in septic patients with high fevers.

Question 5 of 5

A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:

Correct Answer: C

Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.

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