ATI RN
health assessment in nursing test bank Questions
Question 1 of 5
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
Correct Answer: A
Rationale:
Step-by-step rationale:
1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs.
2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions.
3. It guides nurses in planning individualized care to meet patient's specific needs.
4. Medical diagnosis (
B) focuses on disease pathology, not holistic patient care.
5. Admission diagnosis (
C) is a temporary identification of patient's primary reason for admission.
6. Collaborative diagnosis (
D) involves joint identification of interprofessional health problems, not specific to nursing care.
Summary:
The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.
Question 2 of 5
A visiting nurse is making an initial home visit to a patient who has a number of chronic medical problems. Which type of database is most appropriate to collect in this setting?
Correct Answer: C
Rationale: The correct answer is C: A complete health database because of the nurse's primary responsibility for monitoring the patient's health. In this initial home visit, the nurse needs to gather comprehensive information about the patient's medical history, current health status, medications, allergies, and lifestyle factors to establish a baseline for ongoing care. This complete health database will help the nurse make informed decisions and provide personalized care.
Choice A (follow-up database) is incorrect as it is used to evaluate changes over time, not for the initial assessment.
Choice B (episodic database) is incorrect because the patient's chronic medical problems require a more comprehensive approach.
Choice D (emergency database) is incorrect as it is used for urgent situations, not for routine assessments.
Question 3 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 4 of 5
Which of the following responses might the nurse expect during the functional assessment of a patient whose leg is in a cast?
Correct Answer: D
Rationale: The correct answer is D because the nurse would expect the patient to demonstrate functional independence in activities like transferring from a wheelchair to the bed despite having a leg in a cast. This response indicates good mobility and strength, which are positive signs of recovery.
Choices A, B, and C are incorrect as they do not directly address the functional assessment of the patient.
Choice A provides historical information, choice B focuses on pain management, and choice C mentions a self-care routine that is not related to functional ability.
Question 5 of 5
A 90-year-old patient tells the nurse that he is unable to remember the names of the medications he is taking or what they are for. An appropriate response would be:
Correct Answer: D
Rationale: The correct answer is D because asking the patient's family to bring in the medications will ensure accurate identification and understanding of the medications. This step is crucial in ensuring the patient's safety and well-being.
Choice A is incorrect as appearance alone may not provide accurate information.
Choice B is dismissive and does not address the issue.
Choice C focuses on duration rather than addressing the immediate concern of medication identification.