ATI RN
Adult Health Nursing Test Bank Questions
Question 1 of 9
A patient presents with recurrent episodes of brief, severe, stabbing pain in the distribution of the trigeminal nerve. Episodes are triggered by touch, chewing, or cold exposure. Which of the following neurological conditions is most likely responsible for these symptoms?
Correct Answer: D
Rationale: The correct answer is D: Trigeminal neuralgia. This condition is characterized by recurrent, severe, stabbing pain in the trigeminal nerve distribution triggered by touch, chewing, or cold exposure. The key feature is the characteristic lancinating pain, which is not typical of migraine (choice A), cluster headache (choice B), or tension-type headache (choice C). Migraine typically presents with pulsating, moderate to severe headache associated with nausea and sensitivity to light and sound. Cluster headache is characterized by severe, unilateral pain around the eye associated with autonomic symptoms. Tension-type headache presents with bilateral, pressing or tightening pain without specific triggers. Therefore, based on the description of the symptoms in the question, trigeminal neuralgia is the most likely diagnosis.
Question 2 of 9
A nurse is preparing to assist with a lumbar epidural steroid injection (LESI) procedure for a patient with chronic back pain. What action should the nurse prioritize to ensure procedural accuracy?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Confirming the patient's identity ensures the right patient is receiving the intended procedure. 2. Verifying the procedure site using two identifiers prevents errors in site selection. 3. This step aligns with the World Health Organization's Surgical Safety Checklist, reducing the risk of wrong-site procedures. 4. Positioning, sedation, and local anesthesia are important but secondary to ensuring the correct patient and site. Summary: - Option B: Positioning is essential but not the top priority for procedural accuracy. - Option C: Sedation aims to minimize discomfort but does not guarantee procedural accuracy. - Option D: Administering local anesthesia is crucial but not as critical as confirming patient identity and procedure site.
Question 3 of 9
Norse Sophie checks the gauge of the patient ' s intravenous catheter. Which is the smallest gauge catheter that the nurse can use to administer blood?
Correct Answer: B
Rationale: The correct answer is B: 20-Gauge. The smaller the gauge number, the larger the diameter of the catheter. Blood transfusions typically require a larger catheter size to prevent hemolysis and ensure proper flow. A 20-Gauge catheter is larger than 22-Gauge, 18-Gauge, and 12-Gauge, making it suitable for administering blood. 22-Gauge is too small and can cause hemolysis, 18-Gauge is smaller than the recommended size for blood transfusions, and 12-Gauge is too large and can cause damage to the vein.
Question 4 of 9
A patient presents with severe headache, photophobia, and neck stiffness. On examination, there is nuchal rigidity and positive Kernig and Brudzinski signs. Which of the following neurological conditions is most likely responsible for these symptoms?
Correct Answer: C
Rationale: The correct answer is C: Meningitis. The patient's symptoms of severe headache, photophobia, neck stiffness, nuchal rigidity, and positive Kernig and Brudzinski signs are classic signs of meningitis. Meningitis is an inflammation of the meninges surrounding the brain and spinal cord, leading to these specific neurological symptoms. Migraine headache (A) typically presents with a throbbing headache, nausea, and sensitivity to light and sound, but does not typically cause neck stiffness or positive meningeal signs. Cluster headache (B) is characterized by severe unilateral headache with autonomic symptoms like tearing or nasal congestion, but does not typically cause neck stiffness or positive meningeal signs. Subarachnoid hemorrhage (D) presents with sudden severe headache often described as "the worst headache of my life," and may cause neck stiffness, but typically does not present with photophobia or positive meningeal signs like Kernig and Brudzinski signs.
Question 5 of 9
A postpartum client presents with persistent, severe perineal pain and swelling following a vaginal delivery. On assessment, the nurse notes ecchymosis and tenderness of the perineum. Which nursing action is most appropriate?
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The client presenting with persistent, severe perineal pain and swelling, along with ecchymosis and tenderness of the perineum, could be indicative of complications such as a perineal hematoma. A perineal hematoma is a collection of blood in the perineal tissues and can be a serious postpartum complication requiring prompt medical attention. Therefore, it is crucial to alert the healthcare provider so that appropriate assessment, management, and treatment can be initiated promptly. Applying ice packs or encouraging the client to sit on a donut cushion may not be sufficient in this situation, and administering additional analgesic medication should be done only after the healthcare provider has assessed and determined the cause of the symptoms.
Question 6 of 9
A patient presents with severe sore throat, fever, and enlarged tonsils with exudate. Rapid antigen testing confirms group A beta-hemolytic Streptococcus (GAS) infection. Which of the following medications is the first-line treatment for this condition?
Correct Answer: A
Rationale: The correct answer is A: Amoxicillin. Amoxicillin is the first-line treatment for GAS pharyngitis due to its effectiveness against Streptococcus bacteria. It is a penicillin-class antibiotic recommended by guidelines. Azithromycin is an alternative for patients allergic to penicillin. Cephalexin is not the first-line choice for GAS. Clindamycin is reserved for patients allergic to both penicillin and macrolides.
Question 7 of 9
A postpartum client who delivered via cesarean section expresses discomfort when ambulating and performing activities of daily living. What nursing intervention should be prioritized to promote optimal recovery?
Correct Answer: A
Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.
Question 8 of 9
A 20-year-old woman presents with sudden onset of severe lower abdominal pain and missed menstrual periods for the past two months. She has a positive urine pregnancy test. On transvaginal ultrasound, an empty uterus is visualized, and there is fluid in the cul-de-sac. Which condition is most likely to be responsible for these findings?
Correct Answer: B
Rationale: The correct answer is B: Ectopic pregnancy. In this scenario, the combination of missed periods, positive pregnancy test, and empty uterus on ultrasound with fluid in the cul-de-sac is highly suggestive of an ectopic pregnancy. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, commonly in the fallopian tube. The presence of fluid in the cul-de-sac indicates possible blood from a ruptured ectopic pregnancy, causing the severe lower abdominal pain. Ovarian cyst rupture (A) typically presents with less severe pain. Septic abortion (C) would present with signs of infection and products of conception in the uterus. Ovarian torsion (D) would present with acute onset of unilateral lower abdominal pain and a palpable adnexal mass, not fluid in the cul-de-sac.
Question 9 of 9
Lillian complains of unbearable pain. Which of the following characteristics axe EMPHASIZED in a culturally sensitive nursing Care? (Select all that apply) I The expression of pain is affected by learned behavior II. Physiologically, all individuals experience pain in a similar manner, III.. Some Asian people has high response to pain medications IV. Patients should be assessed for pain regardless of overt symptomatology.
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C: I and II): 1. Choice I (The expression of pain is affected by learned behavior) is correct because cultural beliefs and upbringing influence how individuals express and perceive pain. 2. Choice II (Physiologically, all individuals experience pain in a similar manner) is correct because pain perception is largely influenced by biological factors that are universal. 3. Choice III (Some Asian people have a high response to pain medications) is incorrect as it focuses on a specific cultural group, which is not a general characteristic emphasized in culturally sensitive care. 4. Choice IV (Patients should be assessed for pain regardless of overt symptomatology) is incorrect as it is not specifically related to cultural sensitivity in pain management.