ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
Question 2 of 9
A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
Question 3 of 9
A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to avoid which of the following?
Correct Answer: D
Rationale: The correct answer is D: Increasing caffeine consumption. Caffeine can potentially raise blood pressure in individuals with hypertension. The rationale is that caffeine is a stimulant that can lead to temporary spikes in blood pressure. This can be harmful for patients with a history of hypertension as it can exacerbate their condition. A: Increasing potassium intake is generally recommended for individuals with hypertension as it can help lower blood pressure. B: Consuming more fruits and vegetables is also beneficial for hypertension due to their high fiber and nutrient content. C: Limiting sodium intake is crucial for managing hypertension as high sodium levels can lead to increased blood pressure. In summary, increasing caffeine consumption is the correct answer to avoid for patients with hypertension, as it can potentially worsen their condition by raising blood pressure.
Question 4 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 5 of 9
Which of the following statements reflects a component of spirituality?
Correct Answer: C
Rationale: The correct answer is C because spirituality is a personal and intrinsic search for meaning and purpose in life, which is central to the human experience. This definition aligns with the concept of spirituality as a journey of self-discovery and reflection, independent of organized religion or cultural background. Explanation for why other choices are incorrect: A: Worshiping a higher power within an organization implies a religious practice rather than spirituality, which is more individualistic and introspective. B: Attendance at a specific house of worship is a religious practice, not necessarily reflective of spirituality, which can exist outside formal religious institutions. D: While spirituality can be influenced by cultural background, it is not solely tied to it, as it transcends social, ethnic, and historical boundaries.
Question 6 of 9
A nurse is teaching a patient about managing chronic obstructive pulmonary disease (COPD). Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because stopping the inhaler once feeling better is incorrect. Inhalers are used to manage COPD symptoms long-term, not just when feeling unwell. Step 1: Explain that inhalers are essential for managing COPD and should be used consistently. Step 2: Emphasize that stopping inhaler use prematurely can lead to exacerbation of symptoms and worsening of the condition. Step 3: Reinforce the importance of following the prescribed treatment plan for optimal COPD management. Other choices are incorrect: A: True, avoiding second-hand smoke is crucial for COPD management. B: True, taking medications as prescribed is essential. D: True, breathing exercises can help improve lung function.
Question 7 of 9
A nurse is caring for a patient with diabetes who is experiencing hypoglycemia. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In hypoglycemia, the priority is to quickly raise the patient's blood sugar levels to prevent potential complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (A) would further lower blood sugar levels, worsening the situation. Administering an oral hypoglycemic agent (C) is not appropriate in an acute hypoglycemic episode. Monitoring blood pressure (D) is important but not the priority in this situation.
Question 8 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 9 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.