ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint?
Correct Answer: A
Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale: 1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process. 2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration. 3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection. 4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms. Summary: - B: Unlikely as there are no other signs of infection. - C: Unlikely as the pain is described as occasional and sharp. - D:
Question 2 of 9
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.
Question 3 of 9
The clinic nurse is caring for a patient whose grandmother and sister have both had breast cancer. She requested a screening test to determine her risk of developing breast cancer and it has come back positive. The patient asks you what she can do to help prevent breast cancer from occurring. What would be your best response?
Correct Answer: C
Rationale: The correct answer is C: Research has shown that exercising at least 30 minutes every day can reduce your chance of breast cancer. Rationale: 1. Regular exercise helps maintain a healthy weight, which is important in reducing the risk of breast cancer. 2. Physical activity can help regulate hormone levels, such as estrogen, which can affect breast cancer risk. 3. Exercise boosts the immune system and reduces inflammation, both of which play a role in cancer prevention. Summary: A: Eating a healthy diet is important, but it alone cannot provide all the protection needed against breast cancer. B: Tamoxifen may be recommended in some cases, but it is not the primary preventive measure for everyone. D: While genetic predisposition increases risk, lifestyle choices like exercise can still play a significant role in reducing the risk of breast cancer.
Question 4 of 9
A nurse is teaching the staff about informatics.Which information from the staff indicates the nurse needs to follow up?
Correct Answer: C
Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes. A: This is a correct statement about informatics proficiency. B: This is also a correct statement about the skills needed for informatics. D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up. In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.
Question 5 of 9
A smiling patient angrily states, “I will notcough and deep breathe.” How will the nurse interpret this finding?
Correct Answer: C
Rationale: The correct answer is C because the patient's affect, which refers to their emotional expression, is inappropriate. The patient is smiling while expressing anger, which is a contradiction. This inconsistency indicates a possible underlying issue such as emotional distress or confusion. Choice A is incorrect because the issue is not about the patient's understanding of the term "cough and deep breathe." Choice B is incorrect as there is no mention of personal space violation. Choice D is incorrect as the issue is not related to the patient's vocabulary but rather their emotional expression.
Question 6 of 9
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
Correct Answer: C
Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.
Question 7 of 9
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
Correct Answer: B
Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment. A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation. C: Non-pharmacologic pain management is important but not the priority compared to vision loss. D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.
Question 8 of 9
A 57-year-old male comes to the clinic complaining that when he has an erection his penis curves and becomes painful. The patients diagnosis is identified as severe Peyronies disease. The nurse should be aware of what likely treatment modality?
Correct Answer: D
Rationale: The correct answer is D: Surgery. Surgery is the most effective treatment modality for severe Peyronie's disease as it can correct the penile curvature and alleviate pain. Physical therapy (A) may not be effective in severe cases. PDE-5 inhibitors (B) are used for erectile dysfunction but do not treat the underlying Peyronie's disease. Intracapsular hydrocortisone injections (C) may be used for less severe cases, but in severe cases, surgery is recommended for optimal outcomes.
Question 9 of 9
A nurse is assessing the skin integrity of a patient who has AIDS. When performing this inspection, the nurse should prioritize assessment of what skin surfaces?
Correct Answer: A
Rationale: The correct answer is A: Perianal region and oral mucosa. In patients with AIDS, these areas are more prone to opportunistic infections due to decreased immune function. The perianal region can be affected by conditions like anal warts or herpes, while the oral mucosa can develop oral thrush or other oral infections. By prioritizing assessment of these areas, the nurse can promptly identify any potential issues and initiate appropriate interventions. Choice B: Sacral region and lower abdomen are not typically high-risk areas for skin integrity issues in AIDS patients. Choice C: Scalp and skin over the scapulae are not commonly affected by opportunistic infections related to AIDS. Choice D: Axillae and upper thorax are not as commonly affected as the perianal region and oral mucosa in AIDS patients.