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 diabetes. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels, leading to hyperglycemia. This can result in various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. The nurse should monitor the patient's blood glucose levels regularly to prevent these serious complications. Explanation for incorrect choices: A: Hypoglycemia - While hypoglycemia is a concern for diabetic patients, hyperglycemia is a more common and immediate risk. B: Hyperkalemia - While hyperkalemia can occur in some diabetic patients, hyperglycemia is a more common and primary concern. C: Hypotension - While diabetic patients can experience hypotension, hyperglycemia poses a more immediate threat to their health.
Question 2 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 3 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 4 of 9
A patient tells the nurse that she believes in "the hot"“cold theory, where illness is caused by hot or cold entering the body." Which of the following responses from the nurse would be most appropriate?
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.
Question 5 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 6 of 9
A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest. Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.
Question 7 of 9
A nurse is teaching a patient with diabetes about blood glucose management. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions. 2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management. 3. This statement shows the patient's understanding of the need for personalized insulin adjustments. 4. It promotes self-management and proactive approach to blood sugar control. Summary: B: Stopping insulin abruptly can lead to dangerous complications. C: Skipping meals can disrupt blood sugar levels and is not recommended. D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.
Question 8 of 9
A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.
Question 9 of 9
The nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke) and is aphasic. Which of the following is most important to use when assessing mental health in this situation?
Correct Answer: C
Rationale: The correct answer is C: Please point to articles in the room and parts of the body as I name them. This is the most important assessment for mental health in an aphasic patient post-stroke because it evaluates their comprehension, communication abilities, and cognitive function. Pointing to articles and body parts demonstrates understanding and ability to follow instructions, which are crucial aspects of mental health assessment in this context. A: Please count back from 100 by sevens - This choice involves memory and mathematical abilities, which may not accurately assess mental health in an aphasic patient. B: I will name three items and ask you to repeat them in a few minutes - This choice tests memory recall, which is not as relevant for assessing mental health in an aphasic patient post-stroke. D: What would you do if you found a stamped, addressed envelope on the sidewalk? - This choice assesses problem-solving skills, which may not be the most appropriate indicator of mental health in an aphasic patient.