ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A nurse is caring for a 33-year-old male who has come to the clinic for a physical examination. He states that he has not had a routine physical in 5 years. During the examination, the physician finds that digital rectal examination (DRE) reveals stoney hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what?
Correct Answer: C
Rationale: The correct answer is C: Evidence of a more advanced lesion. A stoney hardening in the posterior lobe of the prostate gland that is not mobile is indicative of a more advanced lesion, such as prostate cancer. This finding suggests that the lesion has progressed beyond the early stages. In early prostate cancer, the prostate gland may feel firm but not stoney hard, and the lesion is usually mobile. Metastatic disease would involve spread of the cancer to other parts of the body, which is not evident from the DRE alone. A normal finding would not present as stoney hardening and lack of mobility in the prostate gland during a DRE.
Question 2 of 9
A public health nurse is teaching a health class for the male students at the local high school. The nurse is teaching the boys to perform monthly testicular self-examinations. What point would be appropriate to emphasize?
Correct Answer: A
Rationale: The correct answer is A: Testicular cancer is a highly curable type of cancer. This is the most appropriate point to emphasize because early detection through regular self-examinations can lead to early treatment and a high survival rate. Testicular cancer has a very high cure rate, especially when detected and treated early. Emphasizing this point encourages boys to perform monthly self-exams, leading to early detection and better outcomes. Explanation of other choices: B: Testicular cancer is very difficult to diagnose - This is incorrect because testicular cancer is actually one of the more easily detectable cancers through self-examinations. C: Testicular cancer is the number one cause of cancer deaths in males - This is incorrect as testicular cancer is not the leading cause of cancer deaths in males. D: Testicular cancer is more common in older men - This is incorrect as testicular cancer is more common in younger men, typically between the ages of 15 and 44.
Question 3 of 9
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
Question 4 of 9
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin. Incorrect choices: B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case. C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described. D: Hypocapnia - This is low carbon dioxide levels
Question 5 of 9
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.
Question 6 of 9
An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do?
Correct Answer: C
Rationale: The correct answer is C: Apply petroleum jelly to the affected area. This is because petroleum jelly helps to soothe and protect the skin, reducing dryness and irritation caused by radiation therapy. Ice (A) can further damage the skin, shaving (B) can increase the risk of infection, and soap (D) can be too harsh on the sensitive skin. Therefore, instructing the patient to apply petroleum jelly is the most appropriate recommendation to promote skin healing and comfort.
Question 7 of 9
A nurse is caring for a pregnant patient with active herpes. The teaching plan for this patient should include which of the following?
Correct Answer: A
Rationale: The correct answer is A because babies can become infected with the herpes virus if delivered vaginally. During childbirth, the virus can be passed to the infant, leading to serious health complications. This information is crucial for the patient to understand in order to make informed decisions about delivery options. Choice B is incorrect because excision of herpes lesions is not the recommended treatment during pregnancy. Treatment typically involves antiviral medications to manage symptoms and reduce the risk of transmission to the baby. Choice C is incorrect because herpes outbreaks can indeed be painful during pregnancy due to hormonal changes and a weakened immune system. Pain management strategies should be discussed as part of the teaching plan. Choice D is incorrect because pregnancy can pose a risk to the infant if the mother has active herpes. It is important to manage the condition appropriately to prevent transmission to the baby.
Question 8 of 9
A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this patients nutritional needs?
Correct Answer: B
Rationale: The correct answer is B: TPN administered via a peripherally inserted central catheter. TPN provides comprehensive nutrition intravenously, bypassing the GI tract, which is important for patients unable to tolerate oral intake. A peripherally inserted central catheter allows for long-term TPN administration. A: Administration of parenteral feeds via a peripheral IV is not ideal for long-term nutrition as it may not provide complete nutrition. C: Insertion of an NG tube may not be feasible due to the tumor location and the patient's inability to tolerate oral intake. D: Maintaining NPO status and IV hydration alone may lead to malnutrition over time as it does not provide adequate nutrition.
Question 9 of 9
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby. Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.