ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?
Correct Answer: C
Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.
Question 2 of 5
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.
Question 3 of 5
The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease?
Correct Answer: B
Rationale: The correct answer is B: Facial paralysis. Bell's palsy is characterized by sudden, temporary weakness or paralysis of the facial muscles on one side of the face. This manifests as drooping of the eyelid and corner of the mouth, difficulty smiling or closing the eye. Tinnitus (A) is ringing in the ears, not a common symptom of Bell's palsy. Pain at the base of the tongue (C) is not a typical manifestation of Bell's palsy. Diplopia (D) is double vision, which is not a primary symptom of Bell's palsy. Therefore, the correct manifestation to address in the plan of care for a patient with Bell's palsy is facial paralysis.
Question 4 of 5
A patient with suspected Parkinsons disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?
Correct Answer: A
Rationale: The correct answer is A: When the patient is resting. This is because the tremor associated with Parkinson's disease is most noticeable when the patient is at rest due to the characteristic "resting tremor" seen in this condition. The tremor tends to lessen or disappear with purposeful movements or activities, making it more difficult to assess during ambulation, meal preparation, or occupational therapy. By observing the patient at rest, the nurse can accurately assess the presence and severity of the tremor, which is a key diagnostic feature of Parkinson's disease. Other answer choices are incorrect because they do not provide the optimal condition for assessing the tremor associated with Parkinson's disease.
Question 5 of 5
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to keep his or her feeding area clean. This is the most appropriate independent nursing action as it promotes hygiene and reduces the risk of infection. Keeping the feeding area clean is essential in preventing complications in a patient with malnutrition. Rationales for why the other choices are incorrect: A: Firmly redirect the patient's head when feeding - This is incorrect because forceful redirection can cause distress and discomfort to the patient, potentially leading to aspiration or choking. B: Administer phenothiazines after each meal as ordered - This is incorrect as phenothiazines are not typically used for malnutrition treatment and should not be administered without a specific indication. D: Apply deep, gentle pressure around the patient's mouth to aid swallowing - This is incorrect because applying pressure around the mouth can pose a choking hazard and should not be done without proper assessment and intervention by a speech therapist or swallowing specialist.