ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels. A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure. C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure. D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
Question 2 of 9
A nurse is teaching a patient with asthma about proper inhaler use. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms. A: Holding breath after inhaling helps medication reach lungs. B: Using inhaler before exercise can prevent exercise-induced symptoms. D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.
Question 3 of 9
A nurse is caring for a patient with chronic asthma. The nurse should monitor the patient for which of the following complications of asthma?
Correct Answer: D
Rationale: The correct answer is D: Respiratory failure. In chronic asthma, persistent inflammation and airway remodeling can lead to worsening lung function and respiratory distress, ultimately resulting in respiratory failure. Monitoring for signs of respiratory distress such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. A: Hypoglycemia is not a typical complication of asthma. B: Oxygen toxicity is not a common complication in asthma management unless high concentrations of supplemental oxygen are administered for prolonged periods. C: Hyperkalemia is not directly associated with asthma but may occur as a complication of certain asthma treatments or comorbid conditions. Therefore, the priority complication to monitor in a patient with chronic asthma is respiratory failure due to the progressive nature of the disease and the potential for acute exacerbations.
Question 4 of 9
A nurse is teaching a patient with diabetes about managing their condition. 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 insulin when blood glucose is normal is incorrect. Insulin is necessary for managing diabetes even when blood glucose levels are normal to prevent fluctuations. Monitoring blood glucose (A), exercising (B), and eating a balanced diet (D) are all important components of diabetes management. Stopping insulin abruptly can lead to hyperglycemia and potential complications.
Question 5 of 9
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the:
Correct Answer: A
Rationale: Step-by-step rationale: 1. Nursing interventions are based on nursing diagnosis, which identifies patient's unique health needs. 2. Nursing diagnosis focuses on patient's response to health problems, not just medical conditions. 3. It guides nurses in planning individualized care to meet patient's specific needs. 4. Medical diagnosis (B) focuses on disease pathology, not holistic patient care. 5. Admission diagnosis (C) is a temporary identification of patient's primary reason for admission. 6. Collaborative diagnosis (D) involves joint identification of interprofessional health problems, not specific to nursing care. Summary: The correct answer is A because nursing interventions are tailored based on nursing diagnosis, which considers patient's responses to health issues. Medical diagnosis, admission diagnosis, and collaborative diagnosis do not provide the same level of individualized and holistic care planning as nursing diagnosis.
Question 6 of 9
A nurse is providing education to a patient with chronic liver disease. The nurse should educate the patient to monitor for signs of which of the following complications?
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Patients with chronic liver disease are at risk for developing jaundice due to impaired liver function leading to the accumulation of bilirubin. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates worsening liver function. Incorrect choices: A: Hypoglycemia - Not directly related to chronic liver disease, more commonly seen in diabetes. B: Hyperglycemia - Not typically associated with chronic liver disease unless the patient has underlying diabetes. D: Anemia - Can be a complication of chronic liver disease, but monitoring for jaundice takes priority due to its direct association with liver dysfunction.
Question 7 of 9
A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?
Correct Answer: C
Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.
Question 8 of 9
The nurse is assessing a 75-year-old male patient. At the beginning of the mental status portion of the assessment, the nurse expects that this patient:
Correct Answer: C
Rationale: Rationale for Correct Answer C: - As individuals age, it is normal to experience a slight decline in cognitive abilities, such as response time. - However, general knowledge and abilities are usually well-preserved in older adults. - It is expected that the 75-year-old patient may take a little longer to respond due to age-related changes but should not have a significant decline in general knowledge. Summary of Incorrect Choices: - Choice A is incorrect because it is unrealistic to expect no decrease in any abilities with age. - Choice B is incorrect because while remote memory may decline with age, it is not a universal expectation for all older adults. - Choice D is incorrect as it inaccurately attributes language loss and a decrease in general knowledge to all older adults.
Question 9 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.