ATI RN
health assessment exam 2 test bank Questions
Question 1 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 2 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 3 of 9
A patient has been in the critical care unit for 10 days. He has just been moved to the medical"“surgical unit, and the admitting nurse is planning to perform a mental health examination. During the cognitive function tests, the nurse would expect that he:
Correct Answer: C
Rationale: The correct answer is C. After being in critical care for 10 days, it is expected that the patient may be disoriented to time but still be oriented to place and person. This is a common occurrence due to the stressful and disorienting environment of the critical care unit. The patient's cognition may be temporarily affected, leading to difficulty in remembering the date accurately. The patient's ability to recognize their surroundings and identify themselves and others should still be intact. Choices A, B, and D are incorrect because disruption in thought content, expressing relief, and clouding of consciousness are not typical cognitive function issues expected in this scenario.
Question 4 of 9
Which of the following would be included in a total health database for a well person?
Correct Answer: C
Rationale: The correct answer is C: A patient's perception of his or her health status. In a total health database for a well person, it is important to include the patient's own perception of their health status as it provides valuable insights into their overall well-being and can help detect any potential health issues early on. This information is crucial for preventive care and promoting a patient-centered approach to healthcare. A: Nursing goals for the patient - This information would be relevant for a patient with specific health goals or conditions but not necessarily for a well person. B: Anticipated growth and development patterns - This information is more relevant for pediatric or adolescent populations rather than for a well adult. D: The nurse's perception of disease as related to this patient - The nurse's perception is subjective and not as valuable as the patient's own perception in understanding their health status.
Question 5 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 6 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 to prevent complications?
Correct Answer: A
Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.
Question 7 of 9
A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.
Question 8 of 9
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
Question 9 of 9
During an interview with a patient, at which distance would the nurse expect that most of the interview will take place?
Correct Answer: B
Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.