ATI RN
health assessment exam 1 test bank Questions
Question 1 of 9
A nurse is assessing a 45-year-old male patient with a history of smoking. The nurse would be most concerned if the patient reports:
Correct Answer: A
Rationale: The correct answer is A because shortness of breath with minimal exertion indicates possible respiratory distress, which can be a sign of significant lung damage from smoking. This symptom suggests a decreased ability to exchange oxygen and carbon dioxide efficiently, potentially leading to serious health complications. Choice B is incorrect because an occasional cough with mucus production is common in smokers and may not be as alarming as shortness of breath. Choice C is incorrect as slight wheezing after physical activity could be due to exercise-induced asthma rather than solely smoking-related issues. Choice D is incorrect because even though the patient may not be experiencing symptoms related to smoking currently, it does not rule out potential underlying lung damage or future health risks associated with smoking.
Question 2 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
Question 3 of 9
A nurse is providing discharge instructions to a patient who had a stroke. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.
Question 4 of 9
Which of the following is the appropriate health promotion question to ask during a review of symptoms?
Correct Answer: A
Rationale: The correct answer is A: "Do you use sunscreen while outside?" because it directly relates to health promotion by addressing preventive measures. Sunscreen helps prevent skin cancer and other skin conditions. Choice B is incorrect as it focuses on assessing skin condition rather than promoting health. Choice C is incorrect as it relates to symptoms rather than prevention. Choice D is incorrect as it is related to assessing a specific symptom rather than promoting overall health.
Question 5 of 9
When a nurse is performing a neurological assessment, which of the following is most important to assess first?
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
Question 6 of 9
Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
Question 7 of 9
Which technique should be used to assess a murmur in a patient's heart?
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location. A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs. C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs. D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.
Question 8 of 9
The interview portion of data collection obtains:
Correct Answer: D
Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.
Question 9 of 9
A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:
Correct Answer: A
Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic. Explanation for other choices: B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse. C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness. D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.