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
A patient with osteoporosis is prescribed the bisphosphonate alendronate (Fosamax). What should the nurse include when teaching the patient about this medication? Select all that apply.
Correct Answer: A
Rationale: A. Take the medication as directed with clear water only: Alendronate should be taken with a full glass of plain water on an empty stomach in the morning at least 30 minutes before consuming any food, drink, or other medications. Avoid taking it with any other liquids besides plain water, as other beverages can interfere with the absorption of the drug.
Question 3 of 9
A female patient who was treated 3 months ago for a urinary tract infection is experiencing the same symptoms now. What should the nurse ask the patient during the health assessment?
Correct Answer: D
Rationale: The nurse should ask the patient if she completed the antibiotic prescribed for the first urinary tract infection because it is important to determine if the initial infection was fully treated. If the antibiotic course was not completed as prescribed, it could lead to a recurrence of the infection due to incomplete eradication of the bacteria. Additionally, incomplete treatment can lead to antibiotic resistance, making it harder to treat future infections. Understanding if the patient followed through with the prescribed treatment is crucial in assessing the current situation and planning appropriate interventions.
Question 4 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 5 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 6 of 9
The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care?
Correct Answer: B
Rationale: For a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity, keeping the skin clean and dry, and moisturizing areas of dryness is crucial. Patients with PVD often have compromised circulation to the extremities, which can lead to decreased oxygen and nutrient delivery to tissues, increasing the risk of skin breakdown and impaired wound healing. Proper skin care helps prevent skin breakdown, decreases the risk of infection, and promotes overall skin health. Keeping the skin clean and dry helps prevent skin breakdown, while moisturizing areas of dryness helps maintain skin integrity. This intervention focuses on maintaining skin health and preventing complications associated with compromised circulation in patients with PVD.
Question 7 of 9
A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP?
Correct Answer: B
Rationale: HELLP syndrome is a serious complication of pregnancy characterized by Hemolysis (H), Elevated Liver enzymes (EL), and a Low Platelet count (LP). Therefore, the correct laboratory finding consistent with the diagnosis of HELLP syndrome is hemolysis. This can be indicated by an elevated lactate dehydrogenase (LDH) level, low haptoglobin, elevated bilirubin, and the presence of schistocytes on a blood smear. The other options (A, C, and D) do not align with the classic presentation of HELLP syndrome.
Question 8 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 9 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.