ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
Question 2 of 9
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of exacerbation?
Correct Answer: A
Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications. B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition. C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations. D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.
Question 3 of 9
A nurse is caring for a patient with a history of stroke. The nurse should monitor the patient for signs of:
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.
Question 4 of 9
A nurse is caring for a patient with a history of asthma. The nurse should educate the patient to avoid which of the following triggers?
Correct Answer: B
Rationale: The correct answer is B: Cold, dry air. Cold, dry air is a common trigger for asthma exacerbations, as it can irritate the airways and lead to bronchoconstriction. This trigger can worsen asthma symptoms and increase the risk of an asthma attack. Educating the patient to avoid cold, dry air can help prevent asthma flare-ups. Explanation for why the other choices are incorrect: A: Exercise-induced asthma is triggered by physical activity but can be managed with proper warm-up and medication. It is not typically something to avoid altogether. C: Caffeine is a mild bronchodilator and can actually help alleviate asthma symptoms in some cases. D: Environmental allergens can trigger asthma in some individuals, but they vary from person to person, so avoidance strategies would depend on specific allergens identified through testing.
Question 5 of 9
A nurse is assessing 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 because deep breathing and coughing exercises help prevent complications such as atelectasis and pneumonia after abdominal surgery. By promoting lung expansion and clearing secretions, these exercises enhance oxygenation and prevent respiratory issues. Administering pain medication (A) is important but not the priority. Monitoring for infection (C) and providing wound care (D) are also crucial but come after ensuring respiratory function.
Question 6 of 9
A nurse is caring for a patient who has undergone a colonoscopy. The nurse should prioritize monitoring for which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Bleeding or perforation. After a colonoscopy, the patient is at risk for bleeding or perforation which are serious complications requiring immediate attention. Monitoring for signs such as abdominal pain, rectal bleeding, or signs of peritonitis is crucial. Choice A is not a priority unless the patient shows signs of shock. Choice C is a common post-procedure issue but not a priority complication. Choice D, pain at the insertion site, is expected and can be managed with analgesics.
Question 7 of 9
A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to avoid which of the following?
Correct Answer: D
Rationale: The correct answer is D: Increasing caffeine consumption. Caffeine can potentially raise blood pressure in individuals with hypertension. The rationale is that caffeine is a stimulant that can lead to temporary spikes in blood pressure. This can be harmful for patients with a history of hypertension as it can exacerbate their condition. A: Increasing potassium intake is generally recommended for individuals with hypertension as it can help lower blood pressure. B: Consuming more fruits and vegetables is also beneficial for hypertension due to their high fiber and nutrient content. C: Limiting sodium intake is crucial for managing hypertension as high sodium levels can lead to increased blood pressure. In summary, increasing caffeine consumption is the correct answer to avoid for patients with hypertension, as it can potentially worsen their condition by raising blood pressure.
Question 8 of 9
A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
Correct Answer: D
Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.
Question 9 of 9
In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.