ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
A nurse is performing an assessment on a patientwho has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?
Correct Answer: A
Rationale: The correct answer is A: Hypoactive bowel sounds. When a patient has not had a bowel movement in 3 days, it indicates constipation. Constipation can lead to decreased peristalsis, resulting in hypoactive bowel sounds. Increased fluid intake (B) would be a potential intervention, not an expected assessment finding. A soft tender abdomen (C) may indicate other issues like inflammation or infection, not directly related to constipation. Jaundice in the sclera (D) is indicative of liver dysfunction, not a typical finding associated with constipation.
Question 2 of 9
An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be born with HIV. What is the nurses best response?
Correct Answer: D
Rationale: The correct answer is D because it provides an accurate and comprehensive response to the pregnant patient's question about the risk of her baby being born with HIV. Here's the step-by-step rationale: 1. Option D acknowledges the possibility of the baby contracting HIV at different stages: before, during, or after delivery. This covers all potential scenarios and educates the patient about the risks. 2. By mentioning the different possible transmission times, the nurse highlights the importance of proper prenatal care, delivery planning, and postnatal care to minimize the risk of HIV transmission to the baby. 3. This response empowers the patient with knowledge about the potential risks and emphasizes the importance of seeking appropriate medical interventions to prevent mother-to-child transmission of HIV. 4. In contrast, options A, B, and C provide less informative or inaccurate responses that do not address the patient's concerns adequately, making them incorrect choices. In summary, option D is the best response as it educates the patient about the risks of HIV transmission
Question 3 of 9
A patients most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patients cancer cells spread?
Correct Answer: A
Rationale: The correct answer is A: Hematologic spread. In this case, the cancer cells have traveled through the bloodstream to reach the bones and liver. This process is known as hematologic spread, where cancer cells enter the blood vessels and spread to distant organs. Lymphatic circulation (B) involves the spread of cancer cells through the lymphatic system, which is less likely in this scenario. Invasion (C) refers to cancer cells infiltrating nearby tissues, not distant organs. Angiogenesis (D) is the process of new blood vessel formation to support tumor growth, but it does not explain the spread of cancer cells to other organs.
Question 4 of 9
A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will be screening for relevant cancers. This program is an example of what type of health promotion activity?
Correct Answer: C
Rationale: The correct answer is C: Secondary prevention. This program focuses on screening for relevant cancers, which is a key component of secondary prevention aimed at early detection and treatment to reduce the impact of the disease. Secondary prevention aims to identify and treat health conditions in their early stages. Disease prophylaxis (A) focuses on preventing the occurrence of a disease, while risk reduction (B) aims to lower the chances of developing a disease. Tertiary prevention (D) involves managing and improving outcomes for individuals already diagnosed with a disease. In this scenario, the emphasis on screening aligns closely with the goals of secondary prevention, making it the most appropriate choice.
Question 5 of 9
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Correct Answer: B
Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.
Question 6 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 7 of 9
The nurses assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patients visual acuity?
Correct Answer: B
Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.
Question 8 of 9
The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease?
Correct Answer: B
Rationale: The correct answer is B: Facial paralysis. Bell's palsy is characterized by sudden, temporary weakness or paralysis of the facial muscles on one side of the face. This manifests as drooping of the eyelid and corner of the mouth, difficulty smiling or closing the eye. Tinnitus (A) is ringing in the ears, not a common symptom of Bell's palsy. Pain at the base of the tongue (C) is not a typical manifestation of Bell's palsy. Diplopia (D) is double vision, which is not a primary symptom of Bell's palsy. Therefore, the correct manifestation to address in the plan of care for a patient with Bell's palsy is facial paralysis.
Question 9 of 9
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these symptoms are most likely related to the onset of what complication?
Correct Answer: A
Rationale: The correct answer is A: HIV encephalopathy. This condition, also known as AIDS dementia complex, is characterized by progressive decline in cognitive, behavioral, and motor functions due to HIV affecting the brain. The onset of these symptoms in the patient is indicative of HIV encephalopathy. Explanation for why other choices are incorrect: B: B-cell lymphoma is a type of cancer that can occur in patients with AIDS, but it typically presents with symptoms related to lymph nodes or other organs, not cognitive decline. C: Kaposis sarcoma is a type of cancer caused by the human herpesvirus 8, and it typically presents with skin lesions or internal organ involvement, not cognitive decline. D: Wasting syndrome is characterized by severe weight loss, weakness, and loss of muscle mass, but it does not directly cause cognitive, behavioral, and motor decline as seen in HIV encephalopathy.