ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
A nurse is caring for a patient with chronic heart failure. Which of the following interventions should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administering diuretics as prescribed. Diuretics help reduce fluid retention in patients with heart failure, relieving symptoms like edema and shortness of breath. Prioritizing diuretics can help manage the patient's fluid balance and improve heart function. Encouraging increased fluid intake (B) is contraindicated as it can worsen fluid overload. Restricting sodium intake (C) is important in heart failure management but not the top priority over administering diuretics. Administering pain medications (D) is not a priority intervention for chronic heart failure management.
Question 2 of 9
During an interview with a patient, at which distance would the nurse expect that most of the interview will take place?
Correct Answer: B
Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.
Question 3 of 9
During her prenatal checkup, a patient begins to cry as the nurse asks her about previous pregnancies. The patient says that she is remembering her last pregnancy, which ended in miscarriage. The nurse's best response to her crying would be:
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and validation towards the patient's emotions. By acknowledging the patient's sadness and giving her permission to cry, the nurse creates a safe and supportive environment. This response helps the patient feel understood and accepted, facilitating emotional expression and potentially leading to a deeper therapeutic relationship. Choice A is incorrect because it focuses on the nurse's discomfort rather than the patient's feelings. Choice C is incorrect as it may come across as dismissive of the patient's emotions. Choice D is incorrect as it suggests avoiding the topic rather than addressing the patient's feelings directly.
Question 4 of 9
A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.
Question 5 of 9
Critical thinking in the expert nurse is greatly enhanced by opportunities to:
Correct Answer: A
Rationale: The correct answer is A because applying theory in real situations allows nurses to analyze, evaluate, and problem-solve effectively. This promotes critical thinking by integrating knowledge into practice. Working with physicians (B) and following orders (C) do not directly enhance critical thinking as they focus more on collaboration and task completion. Developing nursing diagnoses (D) is important but does not specifically target critical thinking skills like applying theory does.
Question 6 of 9
The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.
Question 7 of 9
A nurse is caring for a patient with a history of stroke. The nurse should monitor the patient for signs of:
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.
Question 8 of 9
A nurse is caring for a patient with chronic heart failure. The nurse should monitor for which of the following signs of worsening heart failure?
Correct Answer: D
Rationale: The correct answer is D: Pitting edema and weight gain. In chronic heart failure, worsening symptoms indicate fluid retention. Pitting edema in the extremities and weight gain are signs of fluid overload, indicating worsening heart failure. It is crucial for the nurse to monitor these signs to prevent exacerbation. Fatigue and shortness of breath (Choice A) are common symptoms in heart failure but not specific to worsening condition. Increased urine output (Choice B) is not typically seen in worsening heart failure as the kidneys may be compromised. Decreased blood pressure (Choice C) can occur in acute decompensation but is not a consistent sign of worsening chronic heart failure.
Question 9 of 9
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of exacerbation?
Correct Answer: A
Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications. B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition. C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations. D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.