ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine. 2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects. 3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns. Summary of Incorrect Choices: A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines. B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines. D. Taking antihistamines at bedtime may help with sedation, but it does not address
Question 2 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 3 of 9
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine. 2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects. 3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns. Summary of Incorrect Choices: A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines. B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines. D. Taking antihistamines at bedtime may help with sedation, but it does not address
Question 4 of 9
A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patients vomiting is most consistent with a brain tumor?
Correct Answer: C
Rationale: The correct answer is C: The patient's vomiting is unrelated to food intake. In the context of a brain tumor, vomiting that is not related to food intake can indicate increased intracranial pressure affecting the brain's vomiting center. This is known as projectile vomiting. A: Vomiting accompanied by epistaxis (nosebleeds) is more indicative of other conditions like hypertension or nasal issues, not necessarily specific to a brain tumor. B: Vomiting not relieving nausea can be seen in various conditions affecting the gastrointestinal system, not specifically brain tumors. D: Blood-tinged emesis can suggest gastrointestinal bleeding or other issues, but it's not a specific characteristic of vomiting associated with brain tumors.
Question 5 of 9
A patient has sought care, stating that she developed hives overnight. The nurses inspection confirms the presence of urticaria. What type of allergic hypersensitivity reaction has the patient developed?
Correct Answer: A
Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.
Question 6 of 9
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.
Question 7 of 9
Which clinical intervention is the only known cure for preeclampsia?
Correct Answer: B
Rationale: The correct answer is B: Delivery of the fetus. The only known cure for preeclampsia is the delivery of the fetus, as this condition typically resolves after giving birth. Since preeclampsia can lead to serious complications for both the mother and baby, delivering the fetus is the most effective way to stop the progression of the condition. Magnesium sulfate (choice A) is used to prevent seizures in women with severe preeclampsia but does not cure the condition. Antihypertensive medications (choice C) are used to manage blood pressure in preeclampsia but do not cure it. Administration of aspirin (choice D) is used for prevention, not as a cure for preeclampsia.
Question 8 of 9
The patient has just started on enteral feedings, and the patient is reporting abdominal cramping. Which action will the nurse takenext?
Correct Answer: A
Rationale: Correct Answer: A Rationale: Abdominal cramping in a patient on enteral feedings could indicate feeding intolerance. The nurse's initial action should be to slow down the rate of the tube feeding to allow the patient's gastrointestinal tract to adjust gradually. This helps reduce the risk of further complications and allows for better tolerance. Slowing the rate is a safe and effective intervention that can help alleviate the abdominal cramping without causing additional stress on the patient's digestive system. Summary of Incorrect Choices: B: Instilling cold formula is not a recommended practice and can potentially cause harm or discomfort to the patient. C: Changing to a high-fat formula may exacerbate the abdominal cramping as it can be harder to digest for some patients. D: Consulting with the healthcare provider about prokinetic medication should come after trying less invasive interventions such as slowing the rate of tube feeding.
Question 9 of 9
A nurse is using SOLER to facilitate active listening.Which technique should the nurse use for R?
Correct Answer: A
Rationale: The correct answer is A: Relax. In the SOLER technique for active listening, "R" stands for Relax. This technique involves the nurse maintaining a relaxed and open body posture to show attentiveness and create a comfortable environment for the speaker. This helps to build trust and encourages the speaker to express themselves freely. Choice B: Respect is incorrect as it refers to showing respect towards the speaker, which is important in communication but not specifically related to the relaxation aspect of active listening. Choice C: Reminisce is incorrect as it means to recall past experiences or memories, which is not part of the SOLER technique for active listening. Choice D: Reassure is incorrect as it involves providing comfort or support to the speaker, which is different from the relaxation required for active listening.