ATI RN
jarvis physical examination and health assessment 9th edition test bank Questions
Question 1 of 9
A nurse is caring for a patient who has a history of hypertension and reports a new onset of headaches, nausea, and dizziness. The nurse should be most concerned about which of the following?
Correct Answer: A
Rationale: The correct answer is A: Hypertensive crisis. The nurse should be most concerned about this option because the patient has a history of hypertension and is experiencing new onset symptoms such as headaches, nausea, and dizziness, which could indicate a sudden and severe increase in blood pressure. This condition, if left untreated, can lead to serious complications such as stroke or heart attack. Summary: - B: Migraine headache is unlikely as the symptoms described are not typical of a migraine. - C: Benign positional vertigo is unlikely as it does not explain the presence of headaches and nausea. - D: Tension headache is less concerning compared to hypertensive crisis, given the patient's history of hypertension and the severity of symptoms.
Question 2 of 9
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
Question 3 of 9
A nurse is teaching a patient with asthma about managing an asthma attack. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: Rationale: Choice A is correct because using the inhaler at the onset of symptoms can help prevent the asthma attack from worsening. This early intervention can be crucial in managing asthma effectively. Waiting for symptoms to subside (Choice B) can be risky as it may delay necessary treatment. Using the inhaler preventively (Choice C) without symptoms is unnecessary and can lead to overuse. Not using the inhaler for mild symptoms (Choice D) can allow the condition to escalate. Thus, Choice A is the most appropriate response for managing an asthma attack effectively.
Question 4 of 9
When performing a physical assessment, the first technique the nurse will use is:
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
Question 5 of 9
The review of systems provides the nurse with:
Correct Answer: B
Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health. Step 2: It gathers information about symptoms across different body systems. Step 3: This information helps identify potential health risks and guide health promotion practices. Step 4: Choice B is correct as it aligns with the purpose of the review of systems. Summary: - Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment. - Choice C is incorrect as the review of systems is not primarily for teaching medical terms. - Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.
Question 6 of 9
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest. Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.
Question 7 of 9
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.
Question 8 of 9
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery. Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case. Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications. Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.
Question 9 of 9
The nurse is assessing a new patient who has recently immigrated to CanadWhich of the following questions is appropriate to add to the health history questionnaire?
Correct Answer: B
Rationale: The correct answer is B. It is important to know when the patient immigrated and from which country for understanding potential health risks, cultural factors, and access to healthcare. Choice A is too broad and may not yield relevant health information. Choice C focuses on personal reasons for leaving the home country, which may not be medically relevant. Choice D is forward-looking and may not be necessary for the initial assessment.