ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
A patient has been in the critical care unit for 10 days. He has just been moved to the medical"“surgical unit, and the admitting nurse is planning to perform a mental health examination. During the cognitive function tests, the nurse would expect that he:
Correct Answer: C
Rationale: The correct answer is C. After being in critical care for 10 days, it is expected that the patient may be disoriented to time but still be oriented to place and person. This is a common occurrence due to the stressful and disorienting environment of the critical care unit. The patient's cognition may be temporarily affected, leading to difficulty in remembering the date accurately. The patient's ability to recognize their surroundings and identify themselves and others should still be intact. Choices A, B, and D are incorrect because disruption in thought content, expressing relief, and clouding of consciousness are not typical cognitive function issues expected in this scenario.
Question 2 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 3 of 9
A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.
Question 4 of 9
A nurse is caring for a patient who has just had a stroke. Which of the following should the nurse monitor for?
Correct Answer: C
Rationale: The correct answer is C: Respiratory depression. After a stroke, the patient may experience impaired breathing due to neurological damage affecting the respiratory center in the brain. Monitoring for signs of respiratory depression, such as shallow breathing or decreased oxygen saturation, is crucial to prevent respiratory failure. Severe headache (A) may be a symptom of stroke but is not the highest priority for monitoring. Dehydration (B) is important to prevent but not typically a direct consequence of stroke. Sudden loss of vision (D) may occur with certain types of strokes but is not as critical to monitor as respiratory depression.
Question 5 of 9
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse would expect to find which of the following?
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.
Question 6 of 9
A nurse is teaching a patient with diabetes about managing their condition. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A: "I will monitor my blood glucose regularly." This statement shows proper understanding as monitoring blood glucose levels is essential for managing diabetes effectively. Regular monitoring helps the patient track their blood sugar levels and make informed decisions about medication, diet, and lifestyle. Incorrect choices: B: Stopping insulin when blood glucose is normal can lead to dangerous complications. C: Using insulin only when symptoms of high blood sugar are present is not a safe or effective approach. D: Eating sugary foods when feeling tired or weak can cause blood sugar spikes and worsen diabetes control. In summary, choice A is correct because it reflects the importance of consistent blood glucose monitoring in diabetes management, while the other choices suggest potentially harmful misconceptions.
Question 7 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 8 of 9
In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.
Question 9 of 9
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should monitor for signs of which of the following complications?
Correct Answer: C
Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.