ATI RN
foundations of nursing practice questions Questions
Question 1 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 2 of 9
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit?
Correct Answer: D
Rationale: The correct answer is D: Previous perforation of the eardrum. A perforated eardrum can lead to hearing loss as it affects the transmission of sound waves to the inner ear. This is the most likely link to the patient's hearing deficit as trauma or injury to the eardrum can directly impact hearing. Incorrect choices: A: Recent completion of radiation therapy for treatment of thyroid cancer - Radiation therapy for thyroid cancer typically does not directly affect hearing. B: Routine use of quinine for management of leg cramps - Quinine use is associated with tinnitus (ringing in the ears) but not typically with hearing loss. C: Allergy to hair coloring and hair spray - Allergy to hair products is not directly related to hearing loss. In summary, the most likely cause of the patient's hearing deficit based on the health history provided is the previous perforation of the eardrum, as it directly affects the transmission of sound waves to the inner ear.
Question 3 of 9
A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication, which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Administer calcium gluconate. Magnesium sulfate can cause respiratory depression, leading to a low respiratory rate. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on the neuromuscular junction. Administering calcium gluconate helps reverse the respiratory depression caused by magnesium sulfate. Increasing IV fluids (Choice A) is not directly related to treating respiratory depression. Vigorously stimulating the patient (Choice C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (Choice D) may not be effective in addressing the underlying cause of respiratory depression due to magnesium sulfate toxicity.
Question 4 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 5 of 9
A nurse has taught the patient how to use crutches.The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting?
Correct Answer: C
Rationale: Correct Answer: C - Used crutches with no difficulties Rationale: 1. "Used crutches with no difficulties" reflects the patient's successful application of the taught skill. 2. This information indicates the patient's ability to independently perform the task. 3. It demonstrates the effectiveness of the teaching provided by the nurse. 4. "Used crutches with no difficulties" is a specific and objective observation of the patient's performance. Summary: A. "Patient went up and down stairs" is too general and does not indicate the patient's proficiency. B. "Demonstrated use of crutches" does not confirm the patient's actual performance. D. "Deficient knowledge related to never using crutches" is incorrect as it does not reflect the patient's successful use of crutches.
Question 6 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.
Question 7 of 9
A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?
Correct Answer: C
Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.
Question 8 of 9
In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient?
Correct Answer: B
Rationale: The correct answer is B: Saturated fat should be limited to less than 7% of total calories. This is because limiting saturated fat intake is crucial in managing type 1 diabetes to reduce the risk of cardiovascular diseases. Saturated fats can worsen insulin resistance and lead to complications. Choice A is incorrect as diabetic management involves more than just insulin. Choice C is incorrect because nonnutritive sweeteners should be used in moderation due to potential side effects. Choice D is incorrect as individuals with diabetes should aim to keep cholesterol intake low to prevent heart problems.
Question 9 of 9
Which finding in the exam of a patient with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion?
Correct Answer: C
Rationale: The correct answer is C: Clear fluid from vagina. In threatened abortion, there is vaginal bleeding but the cervix is closed, indicating the possibility of the pregnancy continuing. If clear fluid is present, it suggests rupture of the amniotic sac, leading to inevitable abortion. Backache (A) and pelvic pressure (D) can be common symptoms in both threatened and inevitable abortion. A rise in hCG level (B) alone does not indicate a change from threatened to inevitable abortion.