ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Perform a test focused on a neurologic examination. The client's symptoms indicate potential neurological issues, such as vision difficulties and constant nasal drainage, which could be related to nerve damage from the nasal fracture. By performing a neurologic examination, the nurse can assess for any nerve involvement and determine the extent of the injury. This action is crucial in identifying any neurological complications and guiding appropriate treatment. Summary: A: Collecting nasal drainage does not address the client's neurological symptoms. B: Encouraging the client to blow his or her nose could exacerbate the nasal fracture and is not relevant to the neurological symptoms. D: Palpating the nose, face, and neck may help assess the extent of the fracture but does not address the neurological symptoms reported by the client.
Question 2 of 5
A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient?
Correct Answer: C
Rationale: The correct answer is C: Autoimmune disorders. Raynaud's phenomenon is often associated with autoimmune conditions, such as systemic lupus erythematosus or scleroderma. Testing for autoimmune disorders may involve blood tests to check for specific antibodies or inflammatory markers. Hyperglycemia (A) is high blood sugar levels, not directly related to Raynaud's. Hyperlipidemia (B) is high levels of fats in the blood, not typically associated with Raynaud's. Coronary artery disease (D) involves the narrowing of the arteries that supply blood to the heart, which is not directly related to Raynaud's phenomenon.
Question 3 of 5
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction?
Correct Answer: B
Rationale: The correct answer is B because chest pain lasting longer than 30 minutes is a common characteristic of an acute myocardial infarction (heart attack). This prolonged duration indicates cardiac tissue damage. Choices A, C, and D are incorrect. Choice A, pain increasing with deep breathing, is more indicative of musculoskeletal pain. Choice C, pain relieved by nitroglycerin, is suggestive of angina rather than a heart attack. Choice D, reproducible pain with arm movement, is more consistent with musculoskeletal or nerve-related pain rather than a heart attack.
Question 4 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JD) indicates increased pressure in the right atrium. Step 2: When the head of the bed is elevated, gravity helps blood return to the right side of the heart. Step 3: If JD is present with head elevation, it suggests that the right atrial pressure is elevated. Step 4: Elevated right atrial pressure often indicates heart failure or fluid overload. Step 5: Therefore, the correct answer is C: Increased right atrial pressure. Summary: A: Decreased fluid volume is incorrect because JD suggests fluid overload, not decreased volume. B: Jugular vein atherosclerosis is incorrect as JD is not typically associated with atherosclerosis. D: Incompetent jugular vein valves is incorrect as JD is more likely due to increased pressure than valve incompetence.
Question 5 of 5
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
Correct Answer: A
Rationale: Step 1: Assess for anxiety - The client's lack of comprehension, forgetfulness, and repetitive questions indicate potential anxiety affecting their ability to process information. Step 2: Identify potential anxiety cues - Look for signs such as restlessness, increased heart rate, or verbal expressions of worry. Step 3: Address anxiety first - Once anxiety is identified, the nurse can provide appropriate interventions to help the client better understand and retain the information. Step 4: Provide supportive measures - After addressing anxiety, breaking information into smaller bits, giving written information, and reviewing the information can be helpful, but addressing anxiety is key to enhancing the client's ability to comprehend and retain information.