ATI RN
foundation of nursing questions and answers Questions
Question 1 of 9
A nurse and a patient work on strategies to reduceweight. Which phase of the helping relationship is the nurse in with this patient?
Correct Answer: C
Rationale: The correct answer is C: Working. In the working phase, the nurse and patient actively collaborate on achieving goals, such as weight reduction strategies. The nurse assesses, plans, and implements interventions with the patient. During this phase, the focus is on building trust, exploring feelings, and identifying and addressing issues. The other choices are incorrect because in the preinteraction phase (A), there is no direct interaction yet, in the orientation phase (B), the relationship is being established, and in the termination phase (D), the relationship is coming to an end. Thus, the nurse being engaged in weight reduction strategies with the patient indicates that they are in the working phase of the helping relationship.
Question 2 of 9
Which finding would indicate concealed hemorrhage in abruptio placentae?
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention. Rationale: A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae. C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage. D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
Question 3 of 9
A nurse is pouching an ostomy on a patient withan ileostomy. Which action by the nurse ismostappropriate?
Correct Answer: B
Rationale: The correct answer is B, emptying the pouch if it is more than one-third to one-half full. This action is appropriate to prevent leakage and skin irritation. When the pouch becomes too full, it can put pressure on the seal, leading to potential leaks. Emptying the pouch at one-third to one-half fullness helps maintain a secure seal and prevents skin breakdown. Choice A is incorrect because changing the skin barrier portion of the ostomy pouch daily is unnecessary and can lead to skin irritation and breakdown. Choice C is incorrect because cleansing the skin around the stoma with soap and water excessively can strip the skin of its natural oils and cause irritation. Choice D is incorrect because leaving a 1/2-inch space around the stoma when measuring for the barrier device may result in an improper fit, leading to leakage and skin issues.
Question 4 of 9
A patient newly diagnosed with breast cancer states that her physician suspects regional lymph node involvement and told her that there are signs of metastatic disease. The nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis?
Correct Answer: A
Rationale: Rationale for Correct Answer A: Stage IV breast cancer indicates distant metastasis, making the patient ineligible for curative surgery. Treatment for stage IV focuses on palliative care to manage symptoms and improve quality of life. Summary of Other Choices: B: Stage IV breast cancer is not considered highly treatable as it has spread beyond the breast and nearby lymph nodes, making it more challenging to cure. C: There is no evidence to suggest that stage IV breast cancer will self-resolve. The prognosis for metastatic breast cancer is typically poor. D: The 5-year survival rate for stage IV breast cancer is generally lower than 15%, making this choice incorrect.
Question 5 of 9
You are caring for a patient who has been diagnosed with genital herpes. When preparing a teaching plan for this patient, what general guidelines should be taught?
Correct Answer: A
Rationale: The correct answer is A because thorough handwashing is essential in preventing the spread of genital herpes. This helps reduce the risk of transmission to other parts of the body or to other individuals. Sunbathing (B) does not eradicate the virus and can actually worsen symptoms. Massaging lesions with ointment (C) can aggravate the sores and lead to further infection. Self-infection (D) can occur from touching lesions during a breakout due to the highly contagious nature of the virus. Therefore, teaching the patient about thorough handwashing is crucial in managing and preventing the spread of genital herpes.
Question 6 of 9
In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?
Correct Answer: C
Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance. A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain. B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss. D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.
Question 7 of 9
A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?
Correct Answer: A
Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.
Question 8 of 9
A man comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the patients history, what might the nurse note that contributes to erectile dysfunction?
Correct Answer: B
Rationale: The correct answer is B: The patient has a history of hypertension. Hypertension is a risk factor for erectile dysfunction as it can lead to reduced blood flow to the penis, impacting the ability to achieve and maintain an erection. High blood pressure can damage blood vessels and affect the circulation necessary for an erection. Other choices are less likely to directly contribute to erectile dysfunction. A: UTI treatment is not typically associated with erectile dysfunction. C: Age alone is not a direct cause of erectile dysfunction, although it can increase the risk. D: While a sedentary lifestyle can impact overall health, it is less likely to directly cause erectile dysfunction compared to hypertension.
Question 9 of 9
A 76-year-old with a diagnosis of penile cancer has been admitted to the medical floor. Because the incidence of penile cancer is so low, the staff educator has been asked to teach about penile cancer. What risk factors should the educator cite in this presentation? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Phimosis. Phimosis, the inability to retract the foreskin over the glans penis, is a significant risk factor for penile cancer. Phimosis can lead to poor hygiene, inflammation, and chronic irritation, increasing the risk of cancer development. The other choices (B: Priapism, C: Herpes simplex infection, D: Increasing age, E: Lack of circumcision) are not directly linked to penile cancer development. Priapism is prolonged and painful erection unrelated to penile cancer. Herpes simplex infection is a viral infection and not a primary risk factor for penile cancer. Increasing age is a general risk factor for many cancers, but it is not specific to penile cancer. Lack of circumcision has been associated with a slightly higher risk of penile cancer, but it is not as significant as phimosis.