ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?
Correct Answer: D
Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients. A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately. B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds. C: Examining for symmetry is important but not directly related to the optimal position for auscultation.
Question 2 of 9
During an interview, the nurse asks the patient to tell more about their shortness of breath. What is the verbal skill used?
Correct Answer: D
Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.
Question 3 of 9
A nurse is assessing a patient's family history. Which of the following would be most relevant to include in the assessment?
Correct Answer: A
Rationale: The correct answer is A because a family history of heart disease, cancer, and diabetes can provide crucial information about potential genetic predispositions and health risks for the patient. This information helps the nurse assess the patient's risk factors and tailor preventative measures or interventions accordingly. Choice B is incorrect as siblings' hobbies and interests are not relevant to the patient's medical history. Choice C is incorrect as the father's occupation does not directly impact the patient's health risks. Choice D is incorrect as the patient's favorite sports team is not relevant to assessing the patient's family history for health-related issues.
Question 4 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 5 of 9
Which of the following statements best describes the purpose of a health history?
Correct Answer: D
Rationale: The correct answer is D because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.
Question 6 of 9
Canada's population as a whole is aging, and for the first time in Canadian history, which age group has exceeded that of people aged 15 to 24?
Correct Answer: C
Rationale: The correct answer is C: 55-64 years. This age group has exceeded that of people aged 15-24 due to factors like increased life expectancy, lower birth rates, and the aging baby boomer population. This demographic shift impacts workforce, healthcare, and social services. Choice A is incorrect as it represents the youngest age group. Choice B is incorrect as it falls within the working-age group. Choice D is incorrect as it represents the elderly population, which is still lower than the 55-64 age group in this context.
Question 7 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.
Question 8 of 9
A nurse is teaching a patient about managing high cholesterol. Which of the following dietary changes would be most beneficial for lowering cholesterol?
Correct Answer: C
Rationale: The correct answer is C: Decreasing intake of trans fats. Trans fats are known to increase LDL cholesterol levels, which are considered "bad" cholesterol. By reducing trans fats in the diet, the patient can lower their cholesterol levels. Saturated fats (choice A) can also increase LDL cholesterol, so increasing intake is not beneficial. Dietary fiber (choice B) helps lower cholesterol by binding to cholesterol in the digestive system, so decreasing intake would not be beneficial. Processed sugars (choice D) do not directly impact cholesterol levels, so increasing intake would not help lower cholesterol. Overall, choosing option C is the most effective dietary change for managing high cholesterol.
Question 9 of 9
While auscultating for heart sounds, the nurse hears an unfamiliar sounWhat should the nurse do next?
Correct Answer: A
Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.