ATI RN
health assessment exam 1 test bank Questions
Question 1 of 9
A nurse is caring for a patient who is post-operative following a cesarean section. The nurse should prioritize which of the following interventions?
Correct Answer: C
Rationale: The correct answer is C: Monitoring for signs of hemorrhage. This is the priority intervention because post-cesarean section hemorrhage is a life-threatening complication that requires immediate attention. The nurse should monitor the patient's vital signs, uterine firmness, and amount of vaginal bleeding to detect any signs of hemorrhage and take prompt action if necessary. Option A is incorrect because pain management is important but not the priority in this situation. Option B is also incorrect as breastfeeding can be encouraged after the patient's condition is stable. Option D is not the priority as preventing deep vein thrombosis is important but not as urgent as monitoring for hemorrhage.
Question 2 of 9
While auscultating for heart sounds, the nurse hears an unfamiliar sound. What should the nurse do next?
Correct Answer: A
Rationale: The correct answer is A because documenting the findings is essential for accurate patient care and communication among healthcare professionals. By documenting the unfamiliar sound heard during auscultation, the nurse ensures that the information is recorded for future reference and potential follow-up assessments or interventions. Waiting 10 minutes (B) may not address the immediate need for documentation. Asking another nurse to double-check (C) may be helpful but does not address the importance of documenting the finding. Asking the patient to take deep breaths (D) is not the appropriate next step when an unfamiliar heart sound is detected; documentation is crucial before further assessment or intervention.
Question 3 of 9
A nurse is caring for a patient with hypertension. The nurse should educate the patient to avoid which of the following?
Correct Answer: C
Rationale: The correct answer is C: Increasing salt intake. Salt intake can worsen hypertension by causing water retention and increasing blood pressure. Limiting caffeine intake (A) and increasing physical activity (D) are beneficial for managing hypertension. Consuming more fruits and vegetables (B) is also recommended as they are part of a healthy diet that can help lower blood pressure. Overall, educating the patient to avoid increasing salt intake is crucial in managing hypertension effectively.
Question 4 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.
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
In the socioenvironmental model, the focus of the health care provider includes:
Correct Answer: D
Rationale: The correct answer is D because in the socioenvironmental model, the health care provider aims to help the patient view health as a resource. This approach emphasizes empowering patients to take control of their health by recognizing it as an asset that enables them to lead fulfilling lives. By focusing on health as a resource, the provider encourages positive health behaviors and preventive measures. A, changing the patient's perceptions of disease, is incorrect because the socioenvironmental model does not solely target disease perceptions but rather prioritizes health promotion. B, identification of biomedical model interventions, is incorrect as the socioenvironmental model places more emphasis on holistic and social determinants of health rather than solely biomedical interventions. C, identifying the negative health behaviors of the patient, is also incorrect as the model aims to address health behaviors in a positive and empowering way rather than focusing solely on negatives.
Question 7 of 9
Expert nurses learn to attend to a pattern of assessment data and act without consciously labelling it. This is referred to as:
Correct Answer: A
Rationale: The correct answer is A: intuition. Expert nurses develop intuition through years of experience, allowing them to recognize patterns in assessment data and act quickly without conscious labeling. This intuitive response is based on a deep understanding of situations and is often more efficient than consciously going through the nursing process. Clinical knowledge (C) is important but refers to theoretical understanding. The nursing process (B) involves systematic steps in patient care, not the automatic response seen in intuition. Diagnostic reasoning (D) involves a more deliberate thought process in identifying and treating health issues.
Question 8 of 9
A nurse is teaching a patient with chronic kidney disease (CKD) about dietary changes. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A. In CKD, limiting potassium and phosphorus intake is crucial to prevent electrolyte imbalances and further kidney damage. Excessive protein intake can worsen kidney function, so the patient should not eat as much protein as they want. Increasing fluid intake is beneficial for hydration, but sodas are not recommended due to their high sugar and phosphorus content, which can be harmful for CKD patients. Therefore, option A is the best choice for proper understanding of dietary changes in CKD.
Question 9 of 9
A nurse is teaching a patient with asthma about managing triggers. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C: "I should smoke to relieve stress and manage symptoms." This statement indicates a need for further education because smoking can worsen asthma symptoms. Here's the rationale: 1. Smoking is a common trigger for asthma exacerbations due to irritants in tobacco smoke. 2. Smoking can lead to airway inflammation and constriction, making asthma symptoms more severe. 3. Asthma management involves avoiding smoking and secondhand smoke exposure. 4. Choices A, B, and D are correct as they align with asthma management guidelines to avoid triggers and use inhalers as prescribed.