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Concept Level Exam 2
ATI Concept Level Exam 2
Total Questions : 60
Showing 10 questions Sign up for moreA nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client’s medical records.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Explanation
Potential Condition:
- B. Type 1 diabetes mellitus
The client’s symptoms of fatigue, blurred vision, dizziness, and headache, along with a high blood glucose level and HbA1C, suggest that they are experiencing hyperglycemia, a condition common in individuals with Type 1 diabetes mellitus.
Actions to Take:
- B. Teach the client about the signs of hyperglycemia.
- D. Assess the client’s feet for sensation.
Teaching the client about the signs of hyperglycemia will help them recognize when their blood sugar is high and take appropriate action. Assessing the client’s feet for sensation is also important as diabetes can lead to peripheral neuropathy, which can result in a loss of sensation in the feet.
Parameters to Monitor:
- B. Blood pressure
- D. Fingerstick blood glucose
Monitoring the client’s blood pressure is important as hypertension can be a complication of diabetes. Regularly checking the client’s fingerstick blood glucose levels will help ensure that their diabetes is being effectively managed.
Which piece of information should the nurse include in the teaching?
Explanation
Choice A rationale
A moderate amount of swelling is not normal during a testicular self-examination. Any swelling or lumps should be reported to a healthcare provider for further evaluation.
Choice B rationale
The testicles should indeed be examined after a bath or shower. The warmth of the water relaxes the scrotal sac and makes it easier to feel for any abnormalities. This is the correct answer.
Choice C rationale
The testicular self-examination should not be performed twice a week. It is recommended to perform the examination once a month.
Choice D rationale
Abnormalities are not detected by pinching the testicles. Instead, the testicles should be rolled gently between the fingers and thumb to feel for any lumps or bumps.
Where should the nurse expect to find the uterine fundus when palpating the patient’s abdomen?
Explanation
Choice A rationale
At about 12 hours after delivery, the uterine fundus can be palpated at 1 cm above the umbilicus. This is the correct answer.
Choice B rationale
One fingerbreadth above the symphysis pubis is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.
Choice C rationale
At the level of the umbilicus is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.
Choice D rationale
To the right of the umbilicus is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.
After checking the patient’s morning glucose level, what action should the nurse take?
Explanation
Choice A rationale
Administering the insulin 30 minutes after breakfast is not recommended. Regular insulin should be administered before meals.
Choice B rationale
Administering the insulin at 0700 is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.
Choice C rationale
Administering the insulin at 0730 is recommended if breakfast is at 0800. Regular insulin should be administered 30 to 45 minutes before a meal. This is the correct answer.
Choice D rationale
Administering the insulin when the breakfast tray arrives is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.
Which of the following conditions should the nurse mention as an example of a neural tube defect?
Explanation
Choice A rationale
Spina bifida is indeed an example of a neural tube defect. It occurs when the neural tube doesn’t close completely somewhere along the spine during fetal development. This is the correct answer.
Choice B rationale
Cerebral palsy is not a neural tube defect. It is a group of disorders that affect a person’s ability to move and maintain balance and posture.
Choice C rationale
Muscular dystrophy is not a neural tube defect. It is a group of diseases that cause progressive weakness and loss of muscle mass.
Choice D rationale
Hydrocephalus is not a neural tube defect. It is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain.
The patient asks the nurse what will be evaluated during this test.
Which of the following should the nurse include? (Select all that apply.)
Explanation
Choice A rationale
Fetal motion is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its movements16.
Choice B rationale
Fetal neck translucency is not evaluated during a biophysical profile. It is usually measured during an ultrasound examination in the first trimester of pregnancy as a part of screening for chromosomal abnormalities.
Choice C rationale
Fetal gender is not evaluated during a biophysical profile. The focus of a biophysical profile is on the baby’s health, not its gender16.
Choice D rationale
Fetal breathing is indeed evaluated during a biophysical profile. It assesses the health of the baby by observing its breathing movements16.
Choice E rationale
Amniotic fluid volume is indeed evaluated during a biophysical profile. It assesses the health of the baby by measuring the amount of amniotic fluid surrounding the fetus in the uterus16.
After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?
Explanation
Choice A rationale
Frothy pink drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as pulmonary edema where the fluid from the lungs can sometimes appear frothy and pink.
Choice B rationale
Coffee-ground drainage is a common finding in patients with an active upper gastrointestinal bleed. When blood mixes with gastric acid, it can create a substance that resembles coffee grounds. This is often seen when a nasogastric (NG) tube is inserted into the patient.
Choice C rationale
Dark amber drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as liver disease where the urine can sometimes appear dark amber.
Choice D rationale
Greenish-yellow drainage is not typically associated with an upper gastrointestinal bleed. This type of drainage might be seen in other conditions, such as bile duct obstruction where the bile can sometimes appear greenish-yellow.
Which of the following statements should the nurse include in the teaching?
Explanation
Choice A rationale
It is not recommended to increase weight-bearing exercises during pregnancy. Weight-bearing exercises can put additional stress on the joints, which are already under strain due to the increased weight and changes in body shape during pregnancy.
Choice B rationale
It is not necessary to refrain from exercises that include stretching during pregnancy. In fact, gentle stretching can be beneficial to help alleviate some common discomforts of pregnancy such as backache and leg cramps.
Choice C rationale
Moderate exercise does improve circulation. Improved circulation can help reduce swelling, varicose veins, and feelings of fatigue, which are common during pregnancy.
Choice D rationale
It is not necessary to rest for 30 minutes before each new exercise. However, pregnant women should listen to their bodies and rest if they feel tired.
Which of the following statements is a therapeutic response by the nurse?
Explanation
Choice A rationale
Strabismus, or crossed eyes, is a condition that typically requires treatment and is not normal in newborns. It involves a lack of coordination between the muscles that control eye movement, causing the eyes to point in different directions.
Choice B rationale
While it’s important to report concerns to the primary care provider, this statement does not directly address the mother’s concern about her newborn’s crossed eyes.
Choice C rationale
Taking the baby to the nursery for further examination may be necessary in some cases, but it does not provide the mother with immediate reassurance or information about her newborn’s condition.
Choice D rationale
Newborns often lack the muscle control necessary to regulate eye movement, which can cause their eyes to cross. This is a normal part of development and typically resolves on its own within the first few months of life.
Which diagnostic test should the nurse anticipate the healthcare provider will order?
Explanation
Choice A rationale
A sweat test is used to diagnose cystic fibrosis, a genetic disorder that affects the lungs and digestive system. It is not used to diagnose pernicious anemia.
Choice B rationale
Haptoglobin is a protein produced by the liver that binds to hemoglobin in the blood to prevent it from being excreted through the kidneys. While it can be used to diagnose conditions that cause the destruction of red blood cells, it is not used to diagnose pernicious anemia.
Choice C rationale
The Schilling test is used to determine whether the body absorbs vitamin B12 normally, which is crucial for the diagnosis of pernicious anemia. Pernicious anemia is a condition where the body is unable to absorb vitamin B12 due to a lack of intrinsic factor, a protein made in the stomach.
Choice D rationale
Antinuclear antibodies (ANAs) are a type of autoantibody that can attack the body’s own tissues. While they can be present in various autoimmune diseases, they are not used to diagnose pernicious anemia.
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