ATI RN
health assessment test bank jarvis Questions
Question 1 of 9
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function. Rationale: A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure. C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema. D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.
Question 2 of 9
Which food should a client with hypercholesterolemia decrease in their diet?
Correct Answer: B
Rationale: The correct answer is B: hamburgers. Clients with hypercholesterolemia should decrease their intake of foods high in saturated fats, like hamburgers. Saturated fats can raise LDL cholesterol levels. Broiled catfish (A) is a lean protein option, wheat bread (C) is a good source of fiber, and fresh apples (D) are a healthy fruit choice. Hamburgers (B) typically contain high levels of saturated fats from red meat and processed ingredients, making them a less ideal choice for individuals with high cholesterol.
Question 3 of 9
A nurse is taking health history from a patient. The nurse observes the patient's nonverbal behaviors such as hand wringing, avoiding eye contact, and shifting in the seat. Which of the following would be an appropriate response by the nurse?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported. Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.
Question 4 of 9
When formulating diagnostic statements, what would the nurse use?
Correct Answer: D
Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.
Question 5 of 9
What is the nurse's priority when caring for a client with respiratory distress?
Correct Answer: C
Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.
Question 6 of 9
A nurse is caring for a patient with a history of chronic kidney disease. The nurse should monitor for which of the following complications related to decreased renal function?
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to elevated levels in the blood. This can result in life-threatening cardiac arrhythmias. Monitoring for hyperkalemia is crucial in managing patients with kidney disease. Other choices are incorrect because: B: Hypoglycemia is not typically associated with chronic kidney disease. C: Hypotension may occur in kidney disease but is not directly related to decreased renal function. D: Hypercalcemia is not a common complication of decreased renal function; in fact, kidney disease can lead to low levels of calcium.
Question 7 of 9
A man has been admitted to the observation unit after having been treated for a large cut on his foreheaAs the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open packet of cigarettes in his shirt pocket. If using confrontation as a response, the nurse could say:
Correct Answer: D
Rationale: The correct answer is D because using confrontation in this situation involves addressing the discrepancy between the patient's statement and observed behavior without being aggressive or judgmental. By stating, "Mr. K., I know that you are lying," the nurse directly addresses the inconsistency, encouraging honesty and open communication. This approach can help build trust and facilitate a more honest discussion about the patient's tobacco use. Choice A is incorrect as it is too direct and may come across as accusatory. Choice B is also incorrect as it does not acknowledge the discrepancy and may not lead to a productive conversation. Choice C is incorrect as it avoids addressing the issue and focuses on the patient's personal situation instead of the behavior in question.
Question 8 of 9
A nurse is teaching a patient about managing diabetes. Which of the following actions would the nurse emphasize as most important in preventing complications from diabetes?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment. 2. It helps in preventing hypoglycemia or hyperglycemia complications. 3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels. 4. Empowers the patient to make informed decisions regarding their diabetes management. Summary of why the other choices are incorrect: B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity. C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively. D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.
Question 9 of 9
Which of the following statements accurately describes the concept of culturally competent care?
Correct Answer: D
Rationale: Step 1: Culturally competent care involves applying knowledge, skills, attitudes, and personal attributes to provide respectful and effective care. Step 2: Understanding and speaking the patient's mother tongue (Option A) is important but not sufficient for culturally competent care. Step 3: Possessing basic knowledge of the patient's cultural background (Option B) is helpful, but not comprehensive enough to ensure culturally competent care. Step 4: Having knowledge of the significance of social, economic, and cultural contexts (Option C) is crucial but does not encompass the full scope of culturally competent care. Step 5: The correct answer, D, encompasses the holistic approach needed for culturally competent care by emphasizing the application of knowledge, skills, attitudes, and personal attributes to maximize respect and care.