ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.
Question 2 of 9
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of exacerbation?
Correct Answer: A
Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications. B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition. C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations. D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.
Question 3 of 9
The nurse is taking a patient's family history. Important diseases or problems to ask the patient about include:
Correct Answer: C
Rationale: The correct answer is C: mental health issues. When taking a family history, mental health issues are important as they can have a genetic component and can impact the patient's overall health. Emphysema (A) is a respiratory condition, head trauma (B) is not typically hereditary, and fractured bones (D) are usually due to accidents or osteoporosis, not genetic.
Question 4 of 9
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
Question 5 of 9
A nurse is teaching a patient with diabetes about the importance of controlling blood glucose levels. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: The correct answer is B because stopping insulin when blood sugar is normal can lead to hyperglycemia. A: Monitoring blood sugar is essential for diabetes management. C: Eating balanced diet and exercising help control blood sugar levels. D: Avoiding sugary foods is important to manage blood sugar.
Question 6 of 9
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should monitor for signs of which of the following complications?
Correct Answer: C
Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.
Question 7 of 9
A nurse is caring for a patient with a history of asthma. The nurse should educate the patient to avoid which of the following triggers?
Correct Answer: B
Rationale: The correct answer is B: Cold, dry air. Cold, dry air is a common trigger for asthma exacerbations, as it can irritate the airways and lead to bronchoconstriction. This trigger can worsen asthma symptoms and increase the risk of an asthma attack. Educating the patient to avoid cold, dry air can help prevent asthma flare-ups. Explanation for why the other choices are incorrect: A: Exercise-induced asthma is triggered by physical activity but can be managed with proper warm-up and medication. It is not typically something to avoid altogether. C: Caffeine is a mild bronchodilator and can actually help alleviate asthma symptoms in some cases. D: Environmental allergens can trigger asthma in some individuals, but they vary from person to person, so avoidance strategies would depend on specific allergens identified through testing.
Question 8 of 9
A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
Question 9 of 9
A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
Correct Answer: D
Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.