ATI Custom: AH2- FA25- Exam 3
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Free ATI Custom: AH2- FA25- Exam 3 Questions
A nurse is assessing an older adult client who has just been admitted to the medical-surgical unit and presents with a large amount of abdominal ascites. The client is alert and oriented ×3 and states that they walk independently at home and normally use a cane but forgot to bring it to the hospital. Which of the following should be a priority action implemented by the nurse?
- Fall risk protocol
- Sodium restriction diet
- Skin safety protocol
- Bleeding precaution protocol
Explanation
The presence of large abdominal ascites alters the client’s center of gravity, impairs balance, and increases the risk of falls, especially in an older adult who already relies on a cane for mobility. Since the client does not currently have their assistive device, implementing a fall risk protocol is the top priority to ensure immediate safety. This includes providing assistance with ambulation, ensuring the call light is within reach, using nonslip footwear, and possibly arranging a walker or cane while hospitalized. Preventing falls takes precedence before addressing other long-term or secondary issues.
Which four findings are most concerning? (Select All that Apply.)
- Ammonia
- ALT
- AST
- Blood pressure
- Platelets
- Hemoglobin
Explanation
Explanation of Correct Answers
A. Ammonia:
An ammonia level of 94 μmol/L (normal <30) is critically elevated and indicates impaired liver detoxification, consistent with hepatic encephalopathy. Elevated ammonia crosses the blood-brain barrier, leading to confusion, lethargy, and altered mental status. Immediate treatment with lactulose or rifaximin is required to reduce ammonia absorption and prevent progression to coma.
D. Blood pressure:
A blood pressure of 87/42 mm Hg reflects hypotension, suggesting possible circulatory collapse or hemorrhagic shock, likely related to liver dysfunction or gastrointestinal bleeding (common in liver failure). Hypotension compromises organ perfusion, including to the kidneys and brain, and requires immediate fluid resuscitation or vasopressor support.
E. Platelets:
A platelet count of 100 ×10³/μL (normal 150–450) indicates thrombocytopenia, commonly seen in liver failure due to splenomegaly or decreased hepatic synthesis of clotting factors. This significantly increases the risk for spontaneous bleeding, especially in the GI tract or from varices, making it a priority concern.
F. Hemoglobin:
A hemoglobin of 6 g/dL (normal 12–16) is critically low and suggests severe anemia, potentially due to internal bleeding or chronic disease. Such a low level severely reduces oxygen-carrying capacity, causing tachycardia and hypotension. Immediate blood transfusion and monitoring for active bleeding are indicated.
A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)
- Acetone breath
- Fever
- Diabetes mellitus type 2
- Serum glucose 800 mg/dL (74 to 106 mg/dL)
- Serum bicarbonate 15 mEq/L (21 to 28 mEq/L)
- Gradual/slow onset
Explanation
Explanation of Correct Answers
B. Fever
Fever often accompanies HHS because severe dehydration and infection are common precipitating factors. Infection increases insulin resistance and glucose production, worsening hyperglycemia. Elevated temperature also signals systemic stress and fluid loss, both of which are hallmark contributors to HHS development.
C. Diabetes mellitus type 2
HHS occurs almost exclusively in clients with type 2 diabetes mellitus. These individuals produce enough insulin to prevent ketosis but not enough to maintain normal glucose utilization, leading to profound hyperglycemia and hyperosmolarity without significant acidosis.
D. Serum glucose 800 mg/dL (74 to 106 mg/dL)
Extremely high serum glucose levels—typically greater than 600 mg/dL—are a defining characteristic of HHS. Such hyperglycemia causes osmotic diuresis, leading to dehydration, electrolyte imbalance, and altered mental status.
F. Gradual/slow onset
HHS develops slowly over days to weeks, unlike diabetic ketoacidosis (DKA), which presents rapidly. The gradual onset allows for severe dehydration and metabolic disturbances before medical attention is sought.
A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. The client states, "Why do I have to be concerned about protein?" Which of the following responses should the nurse make?
- "A low-protein diet reduces the risk for edema."
- "A low-protein diet will increase the nitrogenous wastes in the blood."
- "A low-protein diet reduces the risk for uremia."
- "A low-protein diet will reduce the risk for hyperkalemia."
Explanation
In chronic kidney failure, the kidneys lose their ability to effectively excrete urea and other nitrogenous wastes produced from protein metabolism. Consuming excessive protein increases the production of these waste products, which accumulate in the bloodstream and lead to uremia—manifested by nausea, vomiting, fatigue, and confusion. A low-protein diet helps decrease urea production, reducing symptoms and slowing progression of kidney damage, while maintaining adequate nutrition through high-biological-value proteins such as eggs and milk.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?
- Finasteride
- Fluoxymesterone
- Methyltestosterone
- Danazol
Explanation
Finasteride is a 5-alpha-reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone (DHT), the hormone responsible for prostate enlargement. This action reduces prostate size over time, improving urinary flow and relieving symptoms of BPH such as urinary retention and frequency. Finasteride is commonly prescribed for long-term management, and clients should be taught that noticeable improvement may take several months of consistent use.
A nurse is providing care for several clients who have type 1 diabetes mellitus. Which of the following clients is most at risk for developing diabetic ketoacidosis (DKA)?
- A client who is awaiting cataract surgery
- A client who is being evaluated for a breast lump
- A client who is receiving IV antibiotics for a urinary tract infection
- A client with a history of Grave’s disease
Explanation
Infection is the most common precipitating factor for diabetic ketoacidosis (DKA) in clients with type 1 diabetes. During infection, the body releases stress hormones such as cortisol and catecholamines, which increase glucose production and reduce insulin effectiveness. This leads to hyperglycemia, fat breakdown, and ketone production, resulting in metabolic acidosis. A client with a urinary tract infection who is receiving IV antibiotics is therefore at the highest risk for developing DKA, especially if insulin doses are missed or poorly absorbed due to illness.
A nurse is preparing discharge instructions for a client who has cirrhosis of the liver. Which of the following statements should be included in the education materials?
- "Ensure that you eat three large meals per day to keep your calories up."
- "Take pain-relief medication such as acetaminophen to relieve discomfort associated with ascites."
- "Increase your activity as much as possible. You need to remain active."
- "Avoid high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners."
Explanation
Clients with cirrhosis are at high risk for fluid retention and ascites due to portal hypertension and hypoalbuminemia. Sodium restriction helps prevent water retention, reduces edema, and minimizes ascitic fluid accumulation. Processed and prepackaged foods are typically high in sodium and should be avoided. The client should instead consume fresh foods and follow a diet that supports liver function and fluid balance.
Based on the client’s assessment findings, which potential condition, nursing actions, and parameters to monitor are most appropriate for this client?
- Potential Condition: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Actions to Take: Administer sodium tablets; Keep client NPO Parameters to Monitor: Serum sodium, Neurological status
- Potential Condition: Diabetic Ketoacidosis (DKA) Actions to Take: Administer insulin; Monitor for peripheral edema Parameters to Monitor: Serum glucose, Arterial blood gases
- Potential Condition: Diabetes Insipidus (DI) Actions to Take: Administer hypotonic fluids; Measure intake and output Parameters to Monitor: Serum sodium, Urine specific gravity
- Potential Condition: Thyroid Storm Actions to Take: Administer beta-blocker; Perform neurological assessments Parameters to Monitor: Temperature, Heart rate
Explanation
The client’s symptoms of confusion, lethargy, excessive thirst, excessive urination, dry skin, tenting, hypotension (80/60 mm Hg), tachycardia (120 bpm), and severe hypernatremia (Na 170 mEq/L) indicate diabetes insipidus (DI), likely caused by chronic lithium use. DI leads to an inability to concentrate urine, resulting in water loss and hypernatremia. The nurse should administer hypotonic fluids (e.g., 0.45% NaCl) to replace free water and measure intake and output closely to prevent dehydration. Monitoring serum sodium ensures gradual correction of hypernatremia, while urine specific gravity helps evaluate renal concentration ability and treatment effectiveness.
A nurse is caring for a client who has an admitted diagnosis of renal calculi and a medical history of hypertension and gout. The client works 6 days a week outside in temperatures between 32.2° C to 37.8° C (90° F to 100° F). Which of the following should the nurse tell the client to prevent a reoccurrence of renal calculi?
- Drink plenty of fluids during the day.
- Eat a diet high in calcium oxalate–rich foods.
- Eat a diet high in purine-rich foods.
- Continue to take your prescribed gout medication.
Explanation
Adequate hydration is the most important measure to prevent recurrence of renal calculi (kidney stones). Working in high temperatures leads to fluid loss through perspiration, concentrating the urine and promoting crystal formation. Drinking plenty of fluids—ideally enough to produce at least 2 liters of urine per day—dilutes the urine and reduces the risk of stone formation, especially in individuals with gout, where uric acid levels may be elevated.
For each finding below, determine whether it is most consistent with Ascites or Elevated Ammonia.
- Increased abdominal girth
- Agitation
- Shortness of breath
- Peripheral edema
- Low serum albumin
- Altered mental status
Explanation
Correct Associations:
A. Increased abdominal girth – Ascites
B. Agitation – Elevated ammonia
C. Shortness of breath – Ascites
D. Peripheral edema – Ascites
E. Low serum albumin – Ascites
F. Altered mental status – Elevated ammonia
Explanation of Correct Answers
A. Increased abdominal girth – Ascites:
Ascites occurs due to fluid accumulation in the abdominal cavity from portal hypertension and low albumin levels. This leads to noticeable abdominal distention and discomfort, as seen in clients with liver failure.
B. Agitation – Elevated ammonia:
An elevated ammonia level (94 μmol/L) reflects hepatic encephalopathy, in which ammonia buildup affects brain function. Clients often exhibit agitation, restlessness, or irritability that may progress to confusion or coma if untreated.
C. Shortness of breath – Ascites:
The buildup of ascitic fluid pushes upward on the diaphragm, restricting lung expansion. This mechanical pressure leads to dyspnea, tachypnea, and labored respirations, consistent with the client’s presentation.
D. Peripheral edema – Ascites:
Fluid retention and decreased oncotic pressure from hypoalbuminemia cause swelling in the legs and feet. Portal hypertension further exacerbates venous congestion, leading to dependent edema.
E. Low serum albumin – Ascites:
A low albumin level (20 g/L) indicates impaired liver protein synthesis. Reduced albumin decreases oncotic pressure, allowing fluid to leak into the peritoneal cavity and contribute to ascites formation.
F. Altered mental status – Elevated ammonia:
Ammonia toxicity from liver dysfunction causes neurological symptoms such as confusion, disorientation, and lethargy. The client’s change in orientation from baseline is consistent with hepatic encephalopathy secondary to elevated ammonia levels.
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