Adult Health Nursing Answer Key

Questions 164

ATI RN

ATI RN Test Bank

Adult Health Nursing Answer Key Questions

Question 1 of 5

Which of the following definition MOST accurately describes meningomyelocele? It is _______.

Correct Answer: C

Rationale: Meningomyelocele is a type of neural tube defect where there is a protrusion of the spinal cord, cerebrospinal fluid, and meninges through a defect in the vertebrae, forming a sac on the surface of the back. This condition occurs during fetal development when the neural tube fails to close completely, leading to the exposure of the spinal cord and its coverings. This herniation can result in a range of neurological deficits and complications, requiring surgical repair shortly after birth to prevent further damage and infections.

Question 2 of 5

Which of the following structures is responsible for the mechanical and chemical digestion of food, as well as the absorption of nutrients into the bloodstream?

Correct Answer: B

Rationale: The stomach is the organ responsible for the mechanical and chemical digestion of food. When food enters the stomach, it is mixed with stomach acid and enzymes to break down the food into smaller particles. This process helps prepare the food for further digestion and absorption of nutrients. The stomach also plays a key role in the absorption of some nutrients, such as certain vitamins and minerals. Additionally, the stomach's muscular contractions help mix the food with digestive enzymes and propel the partially digested food into the small intestine for further processing and absorption. The liver, pancreas, and large intestine have vital functions in the digestive system, but the stomach is the primary organ responsible for the initial digestion and absorption of nutrients.

Question 3 of 5

What is the appropriate initial management for a conscious patient experiencing a syncopal episode (fainting)?

Correct Answer: C

Rationale: The appropriate initial management for a conscious patient experiencing a syncopal episode (fainting) is to provide reassurance and assist the patient to a lying position. This is important to ensure adequate blood flow to the brain and to prevent further injury in case the patient faints again. Elevating the legs above the level of the heart is not recommended as a routine intervention for syncope. Administering intravenous fluids rapidly is not usually needed in the initial management of syncope without signs of dehydration or significant bleeding. Administering oxygen via nasal cannula is not necessary for most cases of syncope unless there are specific indications such as signs of respiratory distress.

Question 4 of 5

The nurse is conducting an assessment to her patient who has edema of the lower extremities due to congestive heart failure. If edema is graded on a scale of +1 (no visible edema in the leg) to 4+ (leg very swollen), what will the Nurse document in her chart if her assessment findings of the edema is SLIGHTLY swollen?

Correct Answer: B

Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.

Question 5 of 5

A few days later, the patient comes into the emergency department via ambulance stretcher and reveals a work-up of blood sugar level at 800mg/dl, ketones are absent in the urine, she is dehydrated, and has an altered mental status. Based on the data, t he patient is most likely suferring from what specifi medical condition?

Correct Answer: A

Rationale: The patient's presentation with a blood sugar level of 800mg/dL, absence of ketones in the urine, dehydration, and altered mental status points towards Hyperosmolar nonketotic coma (HNKC). HNKC typically occurs in patients with Type 2 diabetes and is characterized by extremely high blood glucose levels (hyperglycemia) without significant ketosis. The absence of ketones in the urine distinguishes HNKC from Diabetic ketoacidosis (DKA). Patients with HNKC often present with severe dehydration, altered mental status, and hyperosmolarity. It is crucial to address the underlying cause of the hyperglycemia, correct dehydration, and normalize blood glucose levels promptly in the management of HNKC.

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