ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?
Correct Answer: D
Rationale: The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned. A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described. B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo. C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.
Question 2 of 9
A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk?
Correct Answer: A
Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.
Question 3 of 9
During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently. A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management. B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management. C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
Question 4 of 9
A laboratory finding indicatiNveU oRf SDIICN iGs oTnBe .thCatO sMhows
Correct Answer: A
Rationale: The correct answer is A: decreased fibrinogen. In disseminated intravascular coagulation (DIC), there is widespread activation of coagulation leading to consumption of clotting factors like fibrinogen, resulting in decreased levels. Platelets are usually decreased, not increased, in DIC. Hematocrit may be elevated due to hemoconcentration but not directly related to DIC. Thromboplastin time would be prolonged, not decreased, in DIC due to consumption of clotting factors.
Question 5 of 9
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?
Correct Answer: C
Rationale: The correct answer is C: Risk for infection related to altered immunologic response. This is the priority nursing diagnosis for a patient preparing for hematopoietic stem cell transplant (HSCT) because the patient's immune system will be severely compromised post-transplant, leading to a high risk of infections. It is crucial to prioritize infection prevention to ensure the patient's safety and well-being. Choice A is incorrect because while fatigue is common in cancer patients, it is not the priority in this case where infection risk is higher. Choice B is incorrect as altered nutrition can be addressed after managing the risk for infection. Choice D is incorrect as body image disturbance is important but not as critical as preventing infections in this highly vulnerable patient population.
Question 6 of 9
A nurse is performing a cultural assessment usingthe ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”?
Correct Answer: B
Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.
Question 7 of 9
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage. A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring. C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads. D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.
Question 8 of 9
The nurse is teaching a patient preventative measures regarding vaginal infections. The nurse should include which of the following as an important risk factor?
Correct Answer: D
Rationale: The correct answer is D: Frequent douching. Douching disrupts the natural balance of vaginal flora, making the environment more susceptible to infections. High estrogen levels (A) can actually protect against vaginal infections. Late menarche (B) and nonpregnant state (C) are not direct risk factors for vaginal infections. In summary, frequent douching is the most significant risk factor as it disrupts the vaginal microbiome.
Question 9 of 9
A 60-year-old man presents at the clinic complaining that his breasts are tender and enlarging. The patient is subsequently diagnosed with gynecomastia. The patient should be assessed for the possibility of what causative factor?
Correct Answer: B
Rationale: The correct answer is B: Medication adverse effects. Gynecomastia in a 60-year-old man is often caused by medications like spironolactone, cimetidine, and certain antipsychotics. To determine the causative factor, a thorough medication history review is crucial. Age-related physiologic changes (choice A) do not typically lead to gynecomastia in men. Poor nutrition (choice C) and fluid overload (choice D) are not common causes of gynecomastia in this context.