ATI RN
health assessment test bank Questions
Question 1 of 9
A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom. Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.
Question 2 of 9
What is the first intervention when a client develops symptoms of shock?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.
Question 3 of 9
A woman comes to the clinic complaining of severe itching on her lower legs. Upon examination, the nurse notices red, scaly patches on the skin. The nurse suspects that this is:
Correct Answer: A
Rationale: The correct answer is A: Psoriasis. Psoriasis is characterized by red, scaly patches on the skin, which align with the symptoms described. Psoriasis commonly affects the lower legs and is associated with severe itching. Eczema (choice B) is characterized by red, inflamed, and itchy skin patches, but typically presents differently from psoriasis. Contact dermatitis (choice C) is a localized reaction that occurs when the skin comes into contact with an irritant or allergen, and fungal infections (choice D) typically present with itching, redness, and sometimes peeling skin, but not necessarily scaly patches like psoriasis.
Question 4 of 9
Which quadrant of the abdomen is tender in suspected appendicitis?
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
Question 5 of 9
What should be done for a client who is post-op and develops a fever within the first 48 hours?
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.
Question 6 of 9
What is the most appropriate intervention for a client with severe nausea and vomiting?
Correct Answer: A
Rationale: The correct answer is A: Administer antiemetics. Antiemetics help alleviate nausea and vomiting by blocking neurotransmitters in the brain. This intervention directly targets the symptoms and provides relief for the client. Administering fluids (B) may help with hydration but does not address the root cause. Administering analgesics (C) is for pain relief, not for nausea and vomiting. Monitoring electrolytes (D) is important but does not directly treat the symptoms. Therefore, administering antiemetics is the most appropriate intervention for severe nausea and vomiting.
Question 7 of 9
A nurse is caring for a patient who is post-operative following a lung resection. The nurse should monitor for which of the following signs of complications?
Correct Answer: A
Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early. Incorrect choices: B: Constipation and abdominal distension are not directly related to post-operative lung resection complications. C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection. D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.
Question 8 of 9
A nurse is assessing a patient who is experiencing dizziness and weakness. The nurse should prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Blood pressure measurement. Dizziness and weakness can be symptoms of hypotension or low blood pressure. Prioritizing blood pressure measurement is crucial because it can indicate if the patient is at risk of complications like cardiovascular collapse. Pulse oximetry (B) is important for assessing oxygen levels in the blood but may not directly address dizziness and weakness. Blood glucose levels (C) are important but not the priority in this scenario. Cardiac monitoring (D) may be necessary but should come after assessing blood pressure to rule out immediate life-threatening conditions.
Question 9 of 9
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.