ATI RN
health assessment test bank Questions
Question 1 of 9
A nurse is caring for a patient with a history of stroke. The nurse should monitor for which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. Monitoring for DVT is crucial to prevent life-threatening complications like pulmonary embolism. Pulmonary embolism (A) is a potential complication of DVT but not the most direct concern. Hypertension (C) is a common condition but not directly linked to a history of stroke. Hyperglycemia (D) is more commonly associated with diabetes rather than stroke history. Monitoring for DVT in stroke patients is essential for early detection and intervention.
Question 2 of 9
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
Question 3 of 9
What should be the nurse's first action when caring for a client who has a suspected stroke?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's airway. This is the first action because airway patency is the top priority in any emergency situation, including a suspected stroke. Ensuring the client can breathe effectively is crucial to prevent hypoxia and further complications. Administering oxygen (choice B) may be necessary after assessing the airway. Administering aspirin (choice C) should be done after a definitive diagnosis of an ischemic stroke. Performing a CT scan (choice D) is important for diagnosis but is not the first action to take in a suspected stroke scenario.
Question 4 of 9
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following in the immediate post-operative period?
Correct Answer: B
Rationale: The correct answer is B: Encouraging deep breathing and coughing exercises. This is prioritized in the immediate post-operative period to prevent respiratory complications like atelectasis and pneumonia. Deep breathing helps to expand the lungs and coughing helps clear secretions. Administering pain medication (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial but usually done after ensuring respiratory stability. Providing solid food (D) is contraindicated initially to prevent post-operative complications like ileus.
Question 5 of 9
Which of the following statements about the mental health examination is true?
Correct Answer: B
Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.
Question 6 of 9
A woman is describing the problems she is having with her 2-year-old son. "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurse's best verbal response would be:
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively. Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.
Question 7 of 9
What is the best way to assess a client's nutritional status?
Correct Answer: B
Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.
Question 8 of 9
What is the most appropriate intervention for a client with severe nausea and vomiting?
Correct Answer: A
Rationale: The correct answer is A: Administer antiemetics. Antiemetics help alleviate nausea and vomiting by blocking neurotransmitters in the brain. This intervention directly targets the symptoms and provides relief for the client. Administering fluids (B) may help with hydration but does not address the root cause. Administering analgesics (C) is for pain relief, not for nausea and vomiting. Monitoring electrolytes (D) is important but does not directly treat the symptoms. Therefore, administering antiemetics is the most appropriate intervention for severe nausea and vomiting.
Question 9 of 9
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should educate the patient to prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.