ATI RN
foundations of nursing test bank Questions
Question 1 of 9
A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?
Correct Answer: C
Rationale: The correct answer is C: Assessment of nutritional status. Cachexia is a complex metabolic syndrome characterized by weight loss, muscle wasting, and weakness commonly seen in cancer patients. Assessing the patient's nutritional status is crucial to address the underlying causes of cachexia and to develop an appropriate management plan. This assessment includes evaluating dietary intake, weight changes, body composition, and nutritional deficiencies. Choice A: Assessment of peripheral nervous function is not the priority in this case as cachexia is primarily related to metabolic and nutritional issues rather than peripheral nervous system dysfunction. Choice B: Assessment of cranial nerve function is also not the priority since cachexia is not directly associated with cranial nerve dysfunction. Choice D: Assessment of respiratory status may be important in general patient care, but in this case, addressing the underlying nutritional issues that are contributing to cachexia should be the priority.
Question 2 of 9
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
Correct Answer: B
Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.
Question 3 of 9
A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following?
Correct Answer: C
Rationale: The correct answer is C: Viral set point. The viral set point refers to the stable level of HIV in the body after the initial infection. This state indicates a balance between viral replication and the immune response. The other choices are incorrect because: A) Static stage implies no change, which is not the case with HIV levels fluctuating; B) Latent stage refers to a period of inactivity, not the stable state described; D) Window period is the time between infection and detectable antibodies, not the equilibrium state described.
Question 4 of 9
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach. Summary of why the other choices are incorrect: B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage. C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage. D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.
Question 5 of 9
A nurse who sits on the hospitals ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide?
Correct Answer: A
Rationale: The correct answer is A because administering a lethal dose of medication to a patient whose death is imminent directly causes the patient's death, constituting assisted suicide. This action is intentional and aims to end the patient's life. In contrast, choices B, C, and D do not involve intentionally causing the patient's death. Choice B involves a medication error but not with the intent to end the patient's life. Choice C respects the patient's autonomy in refusing treatment. Choice D honors the patient's wishes for end-of-life care. Thus, only choice A aligns with the definition of assisted suicide.
Question 6 of 9
One of the functions of nursing care of the terminally ill is to support the patient and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support patients and their families during this process? Select all that apply.
Correct Answer: C
Rationale: Rationale: Choice C is correct because understanding the illness from the patient's perspective helps nurses provide individualized care. By empathizing with the patient's experience, nurses can tailor support to meet their specific needs. Describing personal experiences (A) may not be appropriate as it shifts the focus from the patient. Encouraging fighting for a cure (B) may not align with the patient's wishes for quality of life. Assisting with life review (D) can be beneficial but may not be a priority for all patients. Providing interventions for end-of-life closure (E) is important, but understanding the illness from the patient's perspective (C) forms the foundation for effective support.
Question 7 of 9
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?
Correct Answer: A
Rationale: The correct answer is A because floaters are commonly caused by age-related changes in the vitreous humor of the eye, such as the formation of tiny fibers or clumps. These floaters are typically harmless and not a cause for concern. Choice B is incorrect because glasses do not affect floaters in the eye. Choice C is incorrect because floaters are not a primary symptom of glaucoma. Choice D is incorrect because weakened ciliary muscles are not typically associated with floaters. Therefore, the most appropriate interpretation is that seeing floaters is a normal aging process of the eye.
Question 8 of 9
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons, but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect is theproblem with the 14-year-old?
Correct Answer: B
Rationale: The correct answer is B: Vulvodynia. Vulvodynia is characterized by chronic vulvar pain or discomfort, including stabbing pain and burning, without an identifiable cause. In this case, the young girl is experiencing these symptoms despite not being sexually active, ruling out other conditions like vulvitis (inflammation of the vulva), vaginitis (inflammation of the vagina), and Bartholin's cyst (fluid-filled swelling near the vaginal opening). The absence of sexual activity suggests that the pain is not related to an infection or trauma, further supporting the diagnosis of vulvodynia.
Question 9 of 9
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin. Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.