ATI RN
health assessment test bank jarvis Questions
Question 1 of 9
A patient is admitted to the hospital with an acute myocardial infarction. The nurse should prioritize which of the following actions?
Correct Answer: D
Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.
Question 2 of 9
A patient with heart failure tells the nurse, "I can't breathe very well at night." The nurse should ask:
Correct Answer: A
Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.
Question 3 of 9
A nurse is teaching a patient with a history of stroke about preventing future strokes. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because stopping medication once blood pressure is normal can lead to a rebound increase in blood pressure, increasing the risk of stroke. A patient with a history of stroke needs to continue taking medications as prescribed to maintain optimal blood pressure control. Statements A, B, and D are all indicative of good stroke prevention strategies, such as managing blood pressure, limiting alcohol intake, and maintaining a healthy lifestyle.
Question 4 of 9
What is the most important intervention for a client with acute pancreatitis?
Correct Answer: D
Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.
Question 5 of 9
A nurse is caring for a patient who is undergoing treatment for cancer. Which of the following symptoms would most likely indicate the need for palliative care?
Correct Answer: D
Rationale: The correct answer is D because palliative care aims to improve the quality of life for patients with serious illnesses like cancer. Severe pain and nausea (A) are common symptoms that palliative care helps manage. Uncontrolled symptoms despite treatment (B) indicate the need for specialized palliative care interventions. Psychosocial support needs (C) are also addressed in palliative care to address emotional and social aspects of the patient's well-being. Therefore, all of the above (D) are indicative of the need for palliative care as it focuses on holistic symptom management and support for the patient.
Question 6 of 9
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
Question 7 of 9
What is the primary concern for a nurse caring for a client who is post-operative and experiencing confusion?
Correct Answer: B
Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.
Question 8 of 9
What is the highest priority for a nurse treating a client with a stab wound to the chest?
Correct Answer: A
Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.
Question 9 of 9
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains. Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.