ATI RN
test bank foundations of nursing Questions
Question 1 of 9
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges that many HIV patients use alternative therapies and emphasizes the importance of weighing the benefits and risks. This response shows respect for the patient's autonomy and preferences while also recognizing the need for informed decision-making. Choice A is incorrect because it dismisses complementary therapies outright without considering individual patient needs or preferences. Choice B is incorrect as it suggests avoiding alternative therapies entirely, which may not align with the patient's wishes or experiences. Choice D is incorrect as it presents a false dichotomy between alternative and medical approaches, disregarding the possibility of integrating both types of treatments.
Question 2 of 9
A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?
Correct Answer: C
Rationale: The correct answer is C: Promote positive nitrogen balance. In a postsurgical patient, promoting positive nitrogen balance is crucial for wound healing and tissue repair. This goal helps prevent muscle wasting and promotes overall recovery. A: Reduce dependent nitrogen balance is incorrect as it does not address the need for positive nitrogen balance in wound healing. B: Maintain negative nitrogen balance is incorrect because negative nitrogen balance indicates a loss of protein stores, which is detrimental for healing. D: Facilitate neutral nitrogen balance is incorrect as it does not actively support the increased protein needs for wound repair.
Question 3 of 9
The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention?
Correct Answer: C
Rationale: The correct answer is C because encouraging the patient to verbalize concerns can help alleviate anxiety by allowing the patient to express emotions and fears. This intervention promotes emotional expression and provides an outlet for the patient to discuss their worries. This can lead to increased understanding and support. Incorrect answers: A: Administering antianxiety medications does not address the underlying cause of anxiety and may lead to dependency. B: Instructing the family on planning care does not directly address the patient's anxiety. D: Distracting the patient may provide temporary relief but does not address the root cause of anxiety related to lack of control over health circumstances.
Question 4 of 9
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?
Correct Answer: B
Rationale: The correct answer is B: The patient should be monitored for bone marrow depression. Carbamazepine can cause bone marrow suppression, leading to decreased production of blood cells. Monitoring blood counts is crucial to detect this adverse effect early. Choice A is incorrect as Tegretol can have serious adverse effects, including bone marrow depression. Choice C is incorrect as the main side effects of carbamazepine are related to the central nervous system, not renal dysfunction. Choice D is incorrect as medications like carbamazepine should be started at a low dose and gradually titrated up to minimize side effects.
Question 5 of 9
A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family?
Correct Answer: D
Rationale: The correct answer is D: Risk for injury. Patients with Parkinson's disease are at risk for falls due to symptoms like tremors and impaired balance. Educating the family about fall prevention measures is crucial. Choice A, Risk for infection, is not directly related to Parkinson's disease. Choice B, Impaired spontaneous ventilation, is not a common concern in Parkinson's disease. Choice C, Unilateral neglect, is more commonly seen in conditions like stroke, not Parkinson's disease. Therefore, the most appropriate nursing diagnosis for the patient with Parkinson's disease is addressing the risk for injury to prevent falls.
Question 6 of 9
Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy?
Correct Answer: B
Rationale: The correct answer is B: Mitral valve prolapse. This condition is usually benign during pregnancy because the heart's workload increases, and the mitral valve is a one-way valve that prevents blood from flowing back into the left atrium. Mitral valve prolapse typically does not significantly affect the heart's ability to pump blood efficiently during pregnancy. Rationale: 1. Cardiomyopathy (A) can worsen during pregnancy, leading to complications for both the mother and the fetus. 2. Rheumatic heart disease (C) can cause valve damage, increasing the risk of complications during pregnancy. 3. Congenital heart disease (D) varies in severity and can pose risks during pregnancy, depending on the specific condition. Summary: Mitral valve prolapse is the correct answer as it is less likely to cause significant issues during pregnancy compared to the other options provided.
Question 7 of 9
A woman is considering breast reduction mammoplasty. When weighing the potential risks and benefits of this surgical procedure, the nurse should confirm that the patient is aware of what potential consequence?
Correct Answer: D
Rationale: The correct answer is D: Decreased nipple sensation. During breast reduction mammoplasty, nerves responsible for nipple sensation may be disrupted, leading to decreased sensation in the nipple area. This is an important consequence to consider as it can impact the patient's satisfaction and quality of life post-surgery. Other choices are incorrect because: A: Chronic breast pain is a potential risk of surgery but not a consequence directly related to nipple sensation. B: Unclear mammography results may occur due to breast tissue changes from surgery, but it is not a direct consequence of decreased nipple sensation. C: Increased risk of breast cancer is not a common consequence of breast reduction mammoplasty and is not directly related to nipple sensation.
Question 8 of 9
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful?
Correct Answer: B
Rationale: The correct answer is B: Audiometry. Postoperative audiometry is the most appropriate assessment to determine the success of ossiculoplasty, as it evaluates the patient's hearing function and any improvements made by the surgery. Otoscopy (A) is a visual examination of the ear canal and may not provide comprehensive information on hearing. Balance testing (C) assesses equilibrium and is not directly related to the success of ossiculoplasty. Culture and sensitivity testing (D) of ear discharge is used to identify infections and would not directly indicate the success of the surgery.
Question 9 of 9
A nurse is using the explanatory model to determinethe etiology of an illness. Which questions should the nurse ask? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: What do you call your problem? In the explanatory model, this question helps the nurse understand the patient's perspective and cultural beliefs about their illness. By asking how the patient labels their illness, the nurse gains insight into the patient's understanding of the illness, which can influence their treatment adherence and outcomes. The other options are incorrect because: A: How should your sickness be treated? - This question focuses on treatment preferences rather than understanding the patient's beliefs. C: How does this illness work inside your body? - This question is more aligned with the biomedical model, seeking physiological explanations rather than patient perspectives. D: What do you fear most about your sickness? - While important for assessing emotional aspects, this question does not directly address the patient's explanatory model.