ATI RN
jarvis physical examination and health assessment 9th edition test bank Questions
Question 1 of 5
A nurse is teaching a patient about managing hypertension. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. This statement indicates the need for further education because it suggests the patient plans to stop taking medication once blood pressure is normal, which can lead to hypertension returning. Monitoring blood pressure, taking medication as prescribed, and decreasing sodium intake are all appropriate actions for managing hypertension. Stopping medication abruptly can be dangerous and should only be done under a healthcare provider's guidance.
Question 2 of 5
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest.
Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress.
Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation.
Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.
Question 3 of 5
A nurse is caring for a patient with a history of diabetes. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels, leading to hyperglycemia. This can result in various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. The nurse should monitor the patient's blood glucose levels regularly to prevent these serious complications.
Explanation for incorrect choices:
A: Hypoglycemia - While hypoglycemia is a concern for diabetic patients, hyperglycemia is a more common and immediate risk.
B: Hyperkalemia - While hyperkalemia can occur in some diabetic patients, hyperglycemia is a more common and primary concern.
C: Hypotension - While diabetic patients can experience hypotension, hyperglycemia poses a more immediate threat to their health.
Question 4 of 5
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following to prevent complications?
Correct Answer: A
Rationale:
Correct Answer: A - Encouraging early ambulation
Rationale:
1. Early ambulation helps prevent post-operative complications like blood clots and pneumonia.
2. Movement promotes circulation, aids in lung expansion, and prevents muscle atrophy.
3. It also supports bowel function and helps prevent constipation, a common post-operative issue.
4. Ambulation aids in overall recovery and reduces the risk of complications associated with prolonged immobility.
Other
Choices:
B: Administering pain medication - Important for comfort but not the top priority for preventing complications.
C: Providing wound care and dressing changes - Necessary for wound healing but not the immediate priority to prevent complications.
D: Monitoring for signs of infection - Critical but not the primary intervention to prevent complications immediately post-op.
Question 5 of 5
The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?
Correct Answer: A
Rationale: The correct answer is A: "Try to relax; this behavior is culturally appropriate for this person." In Mexican culture, close proximity during conversations is common and signifies engagement and trust. By understanding cultural differences, the nurse can avoid misinterpreting the behavior. Moving the chair back (choice
B) may be seen as rude. Assuming sexual aggression (choice
C) without evidence is inappropriate. Laughing and asking to move away (choice
D) may embarrass the individual. Understanding and respecting cultural norms is crucial in providing effective care.