ATI RN
health assessment test bank Questions
Question 1 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.
Question 2 of 9
Acyclovir is the drug of choice for which condition?
Correct Answer: B
Rationale: Acyclovir is a nucleoside analog antiviral drug that is specifically effective against herpes simplex virus (HSV) types 1 and 2, as well as varicella-zoster virus (VZV). The drug works by inhibiting viral DNA synthesis. HSV and VZV are both members of the herpes virus family, and acyclovir is most commonly prescribed for infections caused by these viruses. Therefore, the correct answer is B. Choice A (HIV) is incorrect because acyclovir is not effective against HIV. Choice C (CMV) is incorrect because acyclovir is less effective against cytomegalovirus (CMV) compared to HSV and VZV. Choice D (influenza A viruses) is incorrect because acyclovir is not indicated for the treatment of influenza viruses.
Question 3 of 9
What should the nurse monitor when caring for a client receiving anticoagulant therapy?
Correct Answer: B
Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications. Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy. Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy. Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.
Question 4 of 9
Critique the following statement made by the nurse: "I know it may be hard, but you should do what the doctor ordered because he/she is the expert in this field.'
Correct Answer: C
Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making. The other choices are incorrect because: A: This choice focuses on bias, which is not the main issue at hand in this scenario. B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience. D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.
Question 5 of 9
What is the most appropriate action when a client experiences chest pain and has a history of myocardial infarction?
Correct Answer: A
Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the recommended initial medication for chest pain in a client with a history of myocardial infarction. It helps dilate blood vessels, improving blood flow to the heart, and reducing chest pain. Aspirin (choice B) is also usually given to reduce blood clot formation, but nitroglycerin is the priority for immediate relief. Morphine (choice C) may be used if nitroglycerin is ineffective, and beta blockers (choice D) are typically used for long-term management of heart conditions, not for immediate relief of chest pain.
Question 6 of 9
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
Question 7 of 9
Which quadrant of the abdomen is tender in suspected appendicitis?
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.
Question 8 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.
Question 9 of 9
Which of the following best describes the purpose of a functional assessment?
Correct Answer: D
Rationale: The correct answer is D because a functional assessment specifically evaluates an older adult's ability to manage day-to-day activities, such as personal care, meal preparation, and mobility. This assessment helps identify any difficulties the individual may have in performing these essential tasks, which can then inform appropriate interventions or support services. Choices A, B, and C are incorrect because they do not align with the primary focus of a functional assessment, which is to evaluate an individual's functional abilities and independence in daily living tasks, particularly in the context of aging or disability.