ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
Correct Answer: B
Rationale: The correct answer is B: Reassure the patient that she does not have to have sex to be feminine. Rationale: 1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns. 2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities. 3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth. 4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues. Summary: A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
Question 2 of 9
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.
Question 3 of 9
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
Correct Answer: D
Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.
Question 4 of 9
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
Correct Answer: B
Rationale: The correct answer is B: Pink. In a healthy ear, the tympanic membrane should appear pink due to the rich blood supply. This color indicates good vascularization and normal functioning of the ear. Yellowish-white (choice A), gray (choice C), and bluish-white (choice D) are incorrect because they do not reflect the normal color of a healthy tympanic membrane. Yellowish-white may indicate fluid behind the eardrum, gray may suggest infection or inflammation, and bluish-white could indicate poor blood flow or trauma. Therefore, the pink color of the tympanic membrane is the most appropriate and indicative of a healthy ear in this case.
Question 5 of 9
A nurse has included the nursing diagnosis of Risk for Latex Allergy Response in a patients plan of care. The presence of what chronic health problem would most likely prompt this diagnosis?
Correct Answer: D
Rationale: The correct answer is D: Hypogammaglobulinemia. This chronic health problem predisposes individuals to latex allergies due to reduced levels of immunoglobulins, increasing susceptibility to allergic reactions. Latex contains proteins that can trigger immune responses in individuals with compromised immune systems. Choice A: Herpes simplex is a viral infection and does not directly relate to latex allergies. Choice B: HIV weakens the immune system but is not specifically associated with latex allergies. Choice C: Spina bifida is a congenital condition affecting the spinal cord and does not directly impact the likelihood of latex allergies.
Question 6 of 9
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
Correct Answer: A
Rationale: The correct answer is A because providing small, frequent nutrient-dense meals helps maximize kilocalories, which is important for patients with AIDS who may have difficulty maintaining weight due to their compromised immune system. This approach ensures the patient receives essential nutrients and energy to support their immune function. Choice B is incorrect as there is no evidence to suggest that hot meals are more easily tolerated by AIDS patients. Choice C is incorrect because limiting liquids can lead to dehydration, which is especially detrimental for individuals with weakened immune systems. Choice D is incorrect as encouraging the intake of fatty foods may not necessarily provide the necessary nutrients and energy required for immune support in AIDS patients.
Question 7 of 9
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection- related death in oncology patients?
Correct Answer: D
Rationale: The correct answer is D: Assess the integrity of the patients oral mucosa regularly. Myelosuppression leads to decreased white blood cells, increasing infection risk. The oral mucosa can be a common site for infections. Regular assessment helps in early detection and intervention. A: Encouraging small meals does not directly address infection risk in myelosuppressed patients. B: Providing skin care is important for overall patient care but does not directly address the leading cause of infection-related death. C: Assisting with hygiene is important but does not specifically target the leading cause of infection-related death in oncology patients.
Question 8 of 9
Which patient ismostat risk for increased peristalsis?
Correct Answer: B
Rationale: The correct answer is B. Stress, like having three final examinations on the same day, can lead to increased peristalsis due to the activation of the sympathetic nervous system. This can result in faster movement of food through the digestive system. The other choices are incorrect because: A - Ignoring the urge to defecate does not directly relate to increased peristalsis. C - Major depressive disorder is more likely to be associated with decreased peristalsis due to the effects of stress on the body. D - Elderly individuals tend to have reduced peristalsis due to age-related changes in the digestive system.
Question 9 of 9
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?
Correct Answer: C
Rationale: The correct answer is C: Fundal height measurement of 18 cm. This finding suggests a hydatidiform mole because it is larger than expected for a 10-week pregnancy due to excessive trophoblastic proliferation. A: Blood pressure is within normal range. B: Nausea is common in early pregnancy and not specific to a mole. D: History of bright red spotting is more indicative of a miscarriage or other complications, not necessarily a mole.