ATI RN
health assessment in nursing test bank Questions
Question 1 of 5
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but laughs loudly when looking at it. This behaviour is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response.
A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it.
B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior.
C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior.
In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.
Question 2 of 5
A nurse is assessing a patient's family history. Which of the following would be most relevant to include in the assessment?
Correct Answer: A
Rationale: The correct answer is A because a family history of heart disease, cancer, and diabetes can provide crucial information about potential genetic predispositions and health risks for the patient. This information helps the nurse assess the patient's risk factors and tailor preventative measures or interventions accordingly.
Choice B is incorrect as siblings' hobbies and interests are not relevant to the patient's medical history.
Choice C is incorrect as the father's occupation does not directly impact the patient's health risks.
Choice D is incorrect as the patient's favorite sports team is not relevant to assessing the patient's family history for health-related issues.
Question 3 of 5
A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients.
A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately.
B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds.
C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
Question 4 of 5
Which of the following statements best describes the purpose of a health history?
Correct Answer: D
Rationale: The correct answer is D because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.
Question 5 of 5
A nurse is providing education to a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following lifestyle changes?
Correct Answer: A
Rationale: The correct answer is A: Quitting smoking. Smoking is the most important lifestyle change for a patient with COPD as it is the primary cause of the disease and continues to worsen symptoms. Quitting smoking can slow down the progression of COPD, decrease exacerbations, and improve overall lung function.
Summary of other choices:
B: Increasing fluid intake - While staying hydrated is important for overall health, it is not the top priority for a patient with COPD.
C: Increasing physical activity - Exercise is beneficial for COPD patients, but quitting smoking takes precedence as it directly impacts the disease progression.
D: Taking over-the-counter cold medications - Cold medications may provide temporary relief for symptoms, but they do not address the underlying cause of COPD which is smoking.