ATI RN
health assessment in nursing test bank Questions
Question 1 of 9
A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but laughs loudly when looking at it. This behaviour is a display of:
Correct Answer: D
Rationale: The correct answer is D: Inappropriate affect. Inappropriate affect refers to emotions that are not congruent with the situation. In this case, the patient's laughing while describing a horrifying image indicates a disconnect between his emotions and the context. This behavior is commonly seen in schizophrenia, where there is a lack of appropriate emotional response. A: Confusion does not accurately describe the patient's behavior, as he is able to describe the picture and his emotional response to it. B: Ambivalence refers to conflicting emotions or attitudes, which is not evident in the patient's behavior. C: Depersonalization involves feeling detached from oneself or reality, which is not evident in the patient's behavior. In summary, the patient's inappropriate laughter in response to a horrifying image is indicative of inappropriate affect, a common feature of schizophrenia.
Question 2 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 3 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 4 of 9
A nurse is providing education to a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following lifestyle changes?
Correct Answer: A
Rationale: The correct answer is A: Quitting smoking. Smoking is the most important lifestyle change for a patient with COPD as it is the primary cause of the disease and continues to worsen symptoms. Quitting smoking can slow down the progression of COPD, decrease exacerbations, and improve overall lung function. Summary of other choices: B: Increasing fluid intake - While staying hydrated is important for overall health, it is not the top priority for a patient with COPD. C: Increasing physical activity - Exercise is beneficial for COPD patients, but quitting smoking takes precedence as it directly impacts the disease progression. D: Taking over-the-counter cold medications - Cold medications may provide temporary relief for symptoms, but they do not address the underlying cause of COPD which is smoking.
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
An Aboriginal woman who lives away from the reserve has come to the clinic to seek help with regulating her diabetes. In conducting an interview, the nurse's priority involves:
Correct Answer: C
Rationale: The correct answer is C because determining if the patient can afford her medications is crucial in managing her diabetes effectively. Financial constraints can significantly impact a patient's ability to adhere to treatment, leading to poor health outcomes. By addressing affordability, the nurse can ensure the patient can access and comply with the prescribed medications. A, finding out why the patient is not compliant, is not the priority at this stage as addressing affordability comes first. B, reinforcing health teaching related to diet and exercise, is important but secondary to ensuring access to medications. D, sending the patient to the diabetic clinic for follow-up, is not as critical as addressing immediate financial concerns.
Question 7 of 9
A nurse is caring for a patient with a history of diabetes. The nurse should monitor for signs of which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. Patients with diabetes are at risk for high blood sugar levels. Monitoring for hyperglycemia is crucial to prevent complications like diabetic ketoacidosis. Hypoglycemia (B) is low blood sugar, dehydration (C) is not directly related to diabetes unless it causes hyperosmolar hyperglycemic state, and hypotension (D) is low blood pressure, which is not a common complication of diabetes. Regular monitoring for hyperglycemia helps in preventing diabetic complications.
Question 8 of 9
A 90-year-old patient tells the nurse that he is unable to remember the names of the medications he is taking or what they are for. An appropriate response would be:
Correct Answer: D
Rationale: The correct answer is D because asking the patient's family to bring in the medications will ensure accurate identification and understanding of the medications. This step is crucial in ensuring the patient's safety and well-being. Choice A is incorrect as appearance alone may not provide accurate information. Choice B is dismissive and does not address the issue. Choice C focuses on duration rather than addressing the immediate concern of medication identification.
Question 9 of 9
A visiting nurse is making an initial home visit to a patient who has a number of chronic medical problems. Which type of database is most appropriate to collect in this setting?
Correct Answer: C
Rationale: The correct answer is C: A complete health database because of the nurse's primary responsibility for monitoring the patient's health. In this initial home visit, the nurse needs to gather comprehensive information about the patient's medical history, current health status, medications, allergies, and lifestyle factors to establish a baseline for ongoing care. This complete health database will help the nurse make informed decisions and provide personalized care. Choice A (follow-up database) is incorrect as it is used to evaluate changes over time, not for the initial assessment. Choice B (episodic database) is incorrect because the patient's chronic medical problems require a more comprehensive approach. Choice D (emergency database) is incorrect as it is used for urgent situations, not for routine assessments.