ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
A nurse is teaching a patient with heart failure 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: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.
Question 2 of 9
Which medication should be given to treat anemia in clients with renal failure?
Correct Answer: A
Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.
Question 3 of 9
A patient is brought by ambulance to the emergency department with multiple injuries received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How should the nurse proceed with the data collection?
Correct Answer: B
Rationale: The correct answer is B. When a patient with severe injuries is brought to the emergency department, the nurse should prioritize performing a physical examination and initiating lifesaving measures while asking history questions simultaneously. This approach allows for immediate assessment and intervention to address any life-threatening conditions. Gathering history information while performing the examination ensures that critical details are not missed and helps in making timely decisions. Choosing option A could delay lifesaving interventions, while option C is not a priority during the initial assessment of a critically injured patient. Option D is incorrect as it prioritizes lifesaving measures over obtaining important history information during the initial assessment.
Question 4 of 9
In a patient with anisocoria, the nurse would expect to observe:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anisocoria is a condition where pupils are of unequal size. 2. It is typically caused by issues in the eye muscles or nerves controlling pupil size. 3. The nurse would expect to observe pupils of different sizes. 4. Dilated pupils (choice A) and excessive tearing (choice B) are not indicative of anisocoria. 5. An uneven curvature of the lens (choice D) does not directly relate to pupil size differences. Summary: Correct answer C is supported by the definition of anisocoria and its usual presentation. Choices A, B, and D are incorrect as they do not align with the characteristic feature of anisocoria.
Question 5 of 9
The nurse is obtaining history for a 3-month-old infant. During the interview, the mother states,"I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
Correct Answer: A
Rationale: The correct answer is A because drooling is a common sign of teething in infants. The nurse's response should validate the mother's observation to build trust and rapport. Choice B is incorrect because teething can start as early as 3 months. Choice C is incorrect as drooling is a normal developmental milestone in infants. Choice D is incorrect as infants do not consciously control saliva production.
Question 6 of 9
During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.
Question 7 of 9
During assessment, the nurse notices that the skin of a patient of Asian descent is yellowish brown in colour. The skin on the hard and soft palate is, however, pink in colour. From this finding, the nurse could probably rule out:
Correct Answer: B
Rationale: The correct answer is B: Jaundice. Yellowish brown skin coloration along with pink coloration of the hard and soft palate is indicative of jaundice, a condition characterized by elevated levels of bilirubin in the blood. Bilirubin causes a yellowish discoloration of the skin but does not affect the color of the mucous membranes like the hard and soft palate. Pallor (A) refers to paleness of the skin due to decreased blood flow or anemia, not relevant in this case. Cyanosis (C) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, which is not consistent with the presented findings. Iron deficiency (D) may lead to pallor, but it does not cause yellowish brown skin coloration like jaundice.
Question 8 of 9
What is the first priority for a client with chest pain and a history of myocardial infarction?
Correct Answer: D
Rationale: The correct answer is D: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.
Question 9 of 9
A mother brings her child in to the clinic for scalp and hair examination. She says that the child has developed irregularly shaped patches on her head with broken-off, stublike hair, and she is worried that this could be some form of premature baldness. She tells the nurse that the child's hair is always kept very short. The nurse reassures her by telling her that it is:
Correct Answer: D
Rationale: The correct answer is D: trichotillomania, which may be caused by her child habitually twirling her hair in an absent-minded way. Trichotillomania is a psychological disorder where individuals have an irresistible urge to pull out their hair. In this case, the broken-off, stublike hair and irregularly shaped patches on the child's head are indicative of hair pulling rather than a medical condition like folliculitis (choice A), traumatic alopecia (choice B), or tinea capitis (choice C). The child's hair being kept very short does not align with the characteristic of these conditions, making trichotillomania the most likely explanation.