ATI RN
foundations of nursing test bank Questions
Question 1 of 5
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons, but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect is theproblem with the 14-year-old?
Correct Answer: B
Rationale: The correct answer is B: Vulvodynia. Vulvodynia is characterized by chronic vulvar pain or discomfort, including stabbing pain and burning, without an identifiable cause. In this case, the young girl is experiencing these symptoms despite not being sexually active, ruling out other conditions like vulvitis (inflammation of the vulva), vaginitis (inflammation of the vagina), and Bartholin's cyst (fluid-filled swelling near the vaginal opening). The absence of sexual activity suggests that the pain is not related to an infection or trauma, further supporting the diagnosis of vulvodynia.
Question 2 of 5
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage. A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring. C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads. D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.
Question 3 of 5
A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions. Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises. In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
Question 4 of 5
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
Correct Answer: D
Rationale: The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer. Explanation for why the other choices are incorrect: A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer. B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast. C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.
Question 5 of 5
A patient in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The patient shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well to her diagnosis and surgery. What nursing intervention is most appropriate to support this patients coping?
Correct Answer: D
Rationale: The correct answer is D, which is to arrange a referral to a community-based support program. This option is the most appropriate because it offers the patient ongoing support from individuals who understand what she is going through. Community-based support programs can provide a safe space for the patient to share her feelings, connect with others in similar situations, and access additional resources for coping. This intervention focuses on providing the patient with adequate support beyond the immediate recovery period, which is crucial for long-term coping and adjustment. Option A is incorrect as it may not consider the patient's individual needs for support beyond her spouse or partner. Option B may be premature as the patient might need time to process her diagnosis and surgery before moving on to the next phase of treatment. Option C may put undue pressure on the patient to maintain a specific emotional state for the sake of others, which may not be beneficial for her own coping and healing process.