ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
A 75-year-old woman is at the clinic for a preoperative interview. The nurse is aware that the interview with her may take longer than interviews with younger persons. What is the reason for this?
Correct Answer: A
Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.
Question 2 of 9
An Aboriginal woman who lives away from the reserve has come to the clinic to seek help with regulating her diabetes. In conducting an interview, the nurse's priority involves:
Correct Answer: C
Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications. A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.
Question 3 of 9
A nurse is caring for a patient who has been diagnosed with asthma. The nurse should educate the patient to avoid which of the following triggers?
Correct Answer: A
Rationale: The correct answer is A: Cold, dry air. Asthma patients are often triggered by cold, dry air, which can cause airway constriction and worsen symptoms. Warm, humid air can actually help alleviate symptoms by keeping airways moist. Excessive physical activity can also trigger asthma, but it varies among individuals and can be managed with appropriate medication and monitoring. Choice D is incorrect as warm, humid air is not a trigger for asthma.
Question 4 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.
Question 5 of 9
The nurse is assessing a 75-year-old male patient. At the beginning of the mental status portion of the assessment, the nurse expects that this patient:
Correct Answer: C
Rationale: Rationale for Correct Answer C: - As individuals age, it is normal to experience a slight decline in cognitive abilities, such as response time. - However, general knowledge and abilities are usually well-preserved in older adults. - It is expected that the 75-year-old patient may take a little longer to respond due to age-related changes but should not have a significant decline in general knowledge. Summary of Incorrect Choices: - Choice A is incorrect because it is unrealistic to expect no decrease in any abilities with age. - Choice B is incorrect because while remote memory may decline with age, it is not a universal expectation for all older adults. - Choice D is incorrect as it inaccurately attributes language loss and a decrease in general knowledge to all older adults.
Question 6 of 9
Which of the following responses might the nurse expect during the functional assessment of a patient whose leg is in a cast?
Correct Answer: D
Rationale: The correct answer is D because the nurse would expect the patient to demonstrate functional independence in activities like transferring from a wheelchair to the bed despite having a leg in a cast. This response indicates good mobility and strength, which are positive signs of recovery. Choices A, B, and C are incorrect as they do not directly address the functional assessment of the patient. Choice A provides historical information, choice B focuses on pain management, and choice C mentions a self-care routine that is not related to functional ability.
Question 7 of 9
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but laughs loudly when looking at it. This behaviour is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response. A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it. B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior. C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior. In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.
Question 8 of 9
A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels. A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure. C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure. D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
Question 9 of 9
A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?
Correct Answer: C
Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.