ATI RN
Nursing a Concept Based Approach to Learning Test Bank Questions
Question 1 of 9
A patient has been experiencing diarrhea for the past week. What should the nurse do first when caring for this patient?
Correct Answer: A
Rationale: The first action that the nurse should take when caring for a patient experiencing diarrhea is to ask the patient to describe the number and character of daily stools. This assessment is crucial in determining the severity and possible cause of the diarrhea. By understanding the frequency and consistency of the stools, the nurse can evaluate if the diarrhea is due to an infection, a reaction to medications, dietary factors, or other underlying health issues. Based on this assessment, appropriate interventions can then be implemented, which may include further diagnostic tests, fluid replacement therapy, dietary modifications, or medication administration. It is essential to gather this information first before considering other interventions such as abstaining from oral intake or using over-the-counter antidiarrheal medications.
Question 2 of 9
The nurse is caring for a 76-year-old client with a history of angina. What atypical age- related warning sign of a myocardial infarction should the nurse need to include in client teaching?
Correct Answer: D
Rationale: In older adults, particularly those over 65 years of age, atypical symptoms of a myocardial infarction may occur. Abdominal pain is considered an atypical age-related warning sign because older adults may present with subtle or nonspecific symptoms, such as discomfort or pain in the abdomen, rather than the classic chest pain associated with a heart attack. This atypical presentation can lead to delays in seeking medical attention and diagnosis, which can have serious consequences for the client. Therefore, it is important for the nurse to educate older clients about the possibility of experiencing atypical symptoms, such as abdominal pain, in the context of a myocardial infarction.
Question 3 of 9
A client states to the nurse, "I know I have high blood pressure, but I don't want to take medication." Based on this data, which health problem is the client at risk for developing?
Correct Answer: C
Rationale: High blood pressure, also known as hypertension, is a significant risk factor for the development of cardiomyopathy. Cardiomyopathy is a condition where the heart muscle becomes weakened or enlarged, affecting its ability to pump blood effectively. If left untreated, high blood pressure can lead to chronic stress on the heart muscle, ultimately causing cardiomyopathy. The client's reluctance to take medication for high blood pressure puts them at an increased risk of developing cardiomyopathy due to the continued strain on the heart over time. It is essential for the client to understand the potential consequences of uncontrolled hypertension and to work with healthcare providers to find a suitable treatment plan to manage their blood pressure effectively and prevent the development of cardiomyopathy.
Question 4 of 9
The nurse is caring for a client who has been diagnosed with diabetes mellitus. The client must learn how to independently perform fingerstick blood sugar analysis as part of the plan of care. The client says, "I already know what you are attempting to teach because I looked everything up on the internet." Which is the best action by the nurse based on the client's statement?
Correct Answer: D
Rationale: While it is positive that the client has taken the initiative to research the procedure online, it is essential for the nurse to assess the client's actual understanding and ability to perform the fingerstick blood sugar analysis correctly. The best course of action would be for the nurse to watch the client perform a return demonstration of the skill. This will allow the nurse to provide real-time feedback, correct any errors, and ensure that the client is performing the procedure accurately and safely. Watching a return demonstration is a critical step in the client's learning process, as it confirms their comprehension and ability to apply the information effectively. It also enables the nurse to address any misconceptions or gaps in knowledge that may not have been evident from the client's statement alone.
Question 5 of 9
Which best describes how congenital defects are categorized?
Correct Answer: B
Rationale: Congenital defects are categorized according to the pathophysiology and hemodynamics of the defect. This means that defects are grouped based on the underlying mechanisms that lead to the defect and how these abnormalities impact the flow of blood or other bodily functions. This classification allows healthcare providers to better understand the nature of the defect and tailor treatment plans accordingly. It helps in determining the best course of action, whether it be medical management, surgical intervention, or monitoring for potential complications. By categorizing congenital defects in this way, healthcare providers can provide more targeted and effective care for affected individuals.
Question 6 of 9
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?
Correct Answer: C
Rationale: In disseminated intravascular coagulation (DIC), the client is experiencing joint pain due to the formation of microthrombi which can lead to ischemia and inflammation within the joints. Heat application is appropriate as it can help improve circulation, reduce pain, and promote relaxation of the joints. Heat helps to increase blood flow to the affected area, which can aid in reducing pain and stiffness in the joints. Additionally, heat can also help to soothe the inflamed tissues and promote comfort for the client. Splints, cool compresses, and ice are not appropriate interventions for joint pain in DIC and may not provide the same level of relief as heat therapy.
Question 7 of 9
The nurse is caring for a patient with an epiphyseal fracture. What bone classification should the nurse keep in mind when planning this patient’s care?
Correct Answer: B
Rationale: An epiphyseal fracture involves the distal or proximal epiphysis of a long bone, such as the femur, tibia, or humerus. Long bones are characterized by having a long shaft with distinct ends (epiphyses). The epiphysis is the site of bone growth and plays a crucial role in bone development. Therefore, understanding the classification of the bone as long helps the nurse in providing appropriate care for the patient with an epiphyseal fracture, such as monitoring growth plate involvement and ensuring proper immobilization for healing.
Question 8 of 9
The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use?
Correct Answer: B
Rationale: When addressing a client's non-adherence to treatment, a nonjudgmental approach is most effective. This involves showing empathy, understanding, and support without criticizing or condemning the client. By adopting a nonjudgmental attitude, the nurse can create a safe environment for open communication and collaboration to explore the reasons behind the client's non-adherence. This approach helps build trust and rapport, which are essential for promoting positive behavior change and improving treatment adherence. In contrast, being indifferent, demanding, or confrontational can lead to defensiveness, resistance, and further non-adherence in the client.
Question 9 of 9
A patient has been experiencing diarrhea for the past week. What should the nurse do first when caring for this patient?
Correct Answer: A
Rationale: The first action that the nurse should take when caring for a patient experiencing diarrhea is to ask the patient to describe the number and character of daily stools. This assessment is crucial in determining the severity and possible cause of the diarrhea. By understanding the frequency and consistency of the stools, the nurse can evaluate if the diarrhea is due to an infection, a reaction to medications, dietary factors, or other underlying health issues. Based on this assessment, appropriate interventions can then be implemented, which may include further diagnostic tests, fluid replacement therapy, dietary modifications, or medication administration. It is essential to gather this information first before considering other interventions such as abstaining from oral intake or using over-the-counter antidiarrheal medications.