ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.
Question 2 of 9
A nurse is caring for a patient who has been diagnosed with asthma. The nurse should educate the patient to avoid which of the following triggers?
Correct Answer: A
Rationale: The correct answer is A: Cold, dry air. Asthma patients are often triggered by cold, dry air, which can cause airway constriction and worsen symptoms. Warm, humid air can actually help alleviate symptoms by keeping airways moist. Excessive physical activity can also trigger asthma, but it varies among individuals and can be managed with appropriate medication and monitoring. Choice D is incorrect as warm, humid air is not a trigger for asthma.
Question 3 of 9
A 75-year-old woman is at the clinic for a preoperative interview. The nurse is aware that the interview with her may take longer than interviews with younger persons. What is the reason for this?
Correct Answer: A
Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.
Question 4 of 9
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but laughs loudly when looking at it. This behaviour is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response. A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it. B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior. C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior. In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.
Question 5 of 9
During an interview, the nurse asks the patient to tell more about their shortness of breath. What is the verbal skill used?
Correct Answer: D
Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.
Question 6 of 9
A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:
Correct Answer: B
Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia. A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues. C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits. D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.
Question 7 of 9
A nurse is caring for a patient who is post-operative following hip replacement surgery. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation. This is because early ambulation is crucial in preventing complications such as blood clots and muscle atrophy post hip replacement surgery. It helps improve circulation, prevent joint stiffness, and promote healing. Administering pain medication regularly (A) is important but not the top priority. Providing wound care and dressing changes (C) and monitoring for signs of infection (D) are also important but secondary to early ambulation in preventing complications and promoting recovery.
Question 8 of 9
A nurse is caring for a patient who has undergone a knee replacement. The nurse should encourage which of the following to promote recovery?
Correct Answer: B
Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.
Question 9 of 9
Which of the following statements best describes the purpose of a health history?
Correct Answer: D
Rationale: The correct answer is D because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.