ATI RN
jarvis physical examination and health assessment 9th edition test bank Questions
Question 1 of 9
A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following signs of an asthma exacerbation?
Correct Answer: B
Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.
Question 2 of 9
The nurse is assessing a new patient who has recently immigrated to CanadWhich of the following questions is appropriate to add to the health history questionnaire?
Correct Answer: B
Rationale: The correct answer is B. It is important to know when the patient immigrated and from which country for understanding potential health risks, cultural factors, and access to healthcare. Choice A is too broad and may not yield relevant health information. Choice C focuses on personal reasons for leaving the home country, which may not be medically relevant. Choice D is forward-looking and may not be necessary for the initial assessment.
Question 3 of 9
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B because encouraging deep breathing and coughing exercises helps to improve lung function and prevent complications in pneumonia. This intervention can help clear secretions, improve oxygenation, and prevent respiratory distress. Administering antibiotics (choice A) is important but not the priority for immediate patient care. Providing pain relief (choice C) is essential but addressing respiratory function is more critical. Monitoring oxygen saturation levels (choice D) is necessary, but promoting lung function through exercises takes precedence.
Question 4 of 9
A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A because monitoring blood glucose levels regularly is essential for managing diabetes effectively. By monitoring blood glucose levels, the patient can make informed decisions about medication, diet, and exercise. This helps in preventing complications and maintaining blood sugar levels within the target range. Choice B is incorrect because stopping insulin when blood sugar is within the normal range can lead to fluctuations and potential hyperglycemia. Choice C is a good practice but does not specifically address blood sugar management. Choice D is also important but does not encompass all aspects of diabetes management.
Question 5 of 9
A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following signs of an asthma exacerbation?
Correct Answer: B
Rationale: The correct answer is B: Increased wheezing and shortness of breath. During an asthma exacerbation, bronchial airways become inflamed and narrowed, leading to increased wheezing and shortness of breath. This is a classic sign of worsening asthma. Other choices are incorrect because: A) Decreased work of breathing is not expected in an asthma exacerbation as the patient usually struggles to breathe. C) Improved oxygen saturation is unlikely as airway obstruction can lead to decreased oxygen levels. D) Decreased sputum production is not a typical sign of asthma exacerbation; in fact, increased sputum production may occur due to airway inflammation.
Question 6 of 9
A patient is experiencing dizziness, blurred vision, and nausea. The nurse should first assess the patient's:
Correct Answer: B
Rationale: The correct answer is B, Blood pressure. Dizziness, blurred vision, and nausea can be symptoms of hypotension or hypertension. Assessing the patient's blood pressure first is crucial to determine if the symptoms are related to blood pressure fluctuations. Electrolyte levels (A) and blood glucose levels (C) may be assessed later but do not address the immediate concern. Temperature and respiratory rate (D) are important assessments but are not the priority in this scenario where cardiovascular status needs to be evaluated first.
Question 7 of 9
A patient often seems to have difficulty coming up with the right words. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up was so full that I decided to take the stairs.' The nurse will note on his chart that he is using or experiencing:
Correct Answer: C
Rationale: The correct answer is C: Circumlocution. This patient is using circumlocution, which is a communication strategy where a person describes something in a roundabout way instead of using the specific word. In this case, the patient is describing an elevator as "the thing that you step into that goes up." This is a common feature of language difficulties seen in conditions like aphasia. A: Blocking is when a person suddenly stops speaking in the middle of a sentence due to an inability to recall a word, which is not happening in this scenario. B: Neologism is the creation of new words or phrases, which is not evident here. D: Circumstantiality is a speech pattern where the person includes unnecessary details and goes off on tangents, which is not demonstrated in the patient's response.
Question 8 of 9
When nursing diagnoses are being classified, which of the following would be considered a risk diagnosis?
Correct Answer: C
Rationale: The correct answer is C because a risk diagnosis involves identifying potential problems that an individual may develop in the future. This type of diagnosis focuses on preemptive measures to prevent or minimize the risk of these potential issues occurring. This is different from options A, B, and D, which do not pertain to future potential problems but rather current levels of wellness, past problems and goals, and strengths respectively. Therefore, option C best aligns with the concept of risk diagnosis in nursing classification.
Question 9 of 9
Which of the following is an example of a first-level priority problem?
Correct Answer: D
Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.