ATI RN
test bank foundations of nursing Questions
Question 1 of 5
The nurse is caring for a patient of Hispanicdescent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Look at the patient when talking. This is important because maintaining eye contact shows respect, builds trust, and enhances communication with the patient. By looking at the patient, the nurse can also observe nonverbal cues and ensure the patient is engaged in the conversation.
Choice A: Using long sentences can be overwhelming for a patient who may not understand the language, leading to miscommunication.
Choice C: Using breaks in sentences may help the interpreter better convey the message, but looking at the patient is more essential for effective communication.
Choice D: Looking at only nonverbal behaviors neglects the importance of eye contact and direct communication with the patient.
Question 2 of 5
The nurse is caring for a patient who has just had a radical mastectomy and axillary node dissection. When providing patient education regarding rehabilitation, what should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.
Question 3 of 5
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice
A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice
B) is a perception of noise or ringing in the ears. Astigmatism (choice
D) is a refractive error of the eye, not related to involuntary eye movements.
Question 4 of 5
The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?
Correct Answer: C
Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights.
Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy.
Choice B is incorrect as it disregards the patient's cultural beliefs and preferences.
Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.
Question 5 of 5
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
Correct Answer: A
Rationale:
Correct
Answer: A - Care of the cervical collar
Rationale:
1. Care of the cervical collar is essential post-cervical diskectomy to ensure proper immobilization and support.
2. Proper care prevents complications and promotes healing.
3. It is a crucial aspect of discharge education to prevent injury and promote recovery.
Summary of other choices:
B: Technique for performing neck ROM exercises - Important for rehabilitation but not directly related to discharge education post-cervical diskectomy.
C: Home assessment of ABGs - Irrelevant to post-cervical diskectomy discharge education.
D: Techniques for restoring nerve function - Important for recovery but not a primary focus of discharge education.