ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
A nurse is teaching a patient with diabetes about the importance of controlling blood glucose levels. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: The correct answer is B because stopping insulin when blood sugar is normal can lead to hyperglycemia. A: Monitoring blood sugar is essential for diabetes management. C: Eating balanced diet and exercising help control blood sugar levels. D: Avoiding sugary foods is important to manage blood sugar.
Question 2 of 9
When a nurse is assessing a patient's pain level, which of the following questions would be most appropriate?
Correct Answer: A
Rationale: Step 1: Asking the patient to rate pain on a scale of 0 to 10 is a standard pain assessment tool, allowing for quantification and tracking of pain intensity. Step 2: This question helps in understanding the severity of pain objectively. Step 3: It provides a baseline for further pain management interventions. Step 4: Other choices are incorrect as they do not directly address assessing pain intensity or severity. Summary: Option A is the most appropriate as it focuses on quantifying pain, which is crucial for effective pain management. Choices B, C, and D are not as relevant for assessing pain intensity.
Question 3 of 9
The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.
Question 4 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 5 of 9
A nurse is caring for a patient with a history of stroke. The nurse should monitor the patient for signs of:
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.
Question 6 of 9
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
Question 7 of 9
The public's concept of health has changed since the 1950s. Which of the following statements most accurately describes this change?
Correct Answer: A
Rationale: The correct answer is A because it reflects the shift towards a holistic view of health focusing on preventive measures and lifestyle choices. In the 1950s, the emphasis was more on treating diseases rather than preventing them through healthy habits. Choice B is incorrect as it only focuses on identifying pathogens, not overall health. Choice C is incorrect because it emphasizes physician-centered healthcare rather than individual responsibility. Choice D is incorrect as it only considers the absence of symptoms, not overall well-being. Therefore, A is the best choice as it aligns with the modern understanding of health promotion and disease prevention.
Question 8 of 9
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions to prevent complications?
Correct Answer: A
Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.
Question 9 of 9
A nurse is caring for a patient who has undergone a total knee replacement. Which of the following interventions is most important to prevent post-operative complications?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.