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
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
Question 3 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 4 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
Question 5 of 9
Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
Question 6 of 9
A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?
Correct Answer: B
Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.
Question 7 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 8 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 9 of 9
A nurse is caring for a patient with a history of hypertension. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering antihypertensive medication as prescribed. This is the priority intervention because it directly addresses the patient's hypertension, which is a critical condition that needs immediate management to prevent complications. Encouraging weight loss (B), monitoring blood pressure (C), and promoting a low-sodium diet (D) are all important aspects of managing hypertension. However, administering antihypertensive medication takes precedence as it directly targets lowering blood pressure and reducing the risk of cardiovascular events. Weight loss, monitoring, and dietary changes are important for long-term management but may not provide immediate control of hypertension compared to medication.