ATI RN
test bank foundations of nursing Questions
Question 1 of 5
A patients ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patients discharge education?
Correct Answer: A
Rationale: The correct answer is A: Disturbed body image. Enucleation can have a significant impact on a patient's self-image and self-esteem. By addressing this nursing diagnosis, the nurse can help the patient cope with the changes in their physical appearance and support them in adjusting to wearing a prosthesis. Summary: - Choice B (Chronic pain) is incorrect because enucleation may cause acute pain initially, but chronic pain is not a common concern post-enucleation. - Choice C (Ineffective protection) is incorrect because enucleation does not necessarily affect the eye's protection mechanism. - Choice D (Unilateral neglect) is incorrect as it refers to a neurological condition unrelated to the patient's situation post-enucleation.
Question 2 of 5
The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patients health education?
Correct Answer: C
Rationale: The correct answer is C: The need to perform thorough hand hygiene before handling the prosthesis. This is crucial to prevent infection. By washing hands thoroughly, the patient reduces the risk of introducing harmful bacteria or pathogens to the prosthesis, which could lead to infections or other complications. Incorrect Choices: A: The need to limit exposure to bright light - This is not directly related to caring for an ocular prosthesis. B: The need to maintain a low Fowlers position when removing the prosthesis - Positioning is not typically a concern when caring for an ocular prosthesis. D: The need to apply antiviral ointment to the prosthesis daily - Antiviral ointment is not a standard part of ocular prosthesis care unless specifically prescribed by a healthcare provider for a particular reason.
Question 3 of 5
The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively?
Correct Answer: B
Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.
Question 4 of 5
A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
Correct Answer: B
Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment. A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation. C: Non-pharmacologic pain management is important but not the priority compared to vision loss. D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.
Question 5 of 5
The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa?
Correct Answer: C
Rationale: The correct answer is C: Pain on manipulation of the auricle is characteristic of otitis externa. This is because otitis externa is an infection or inflammation of the outer ear canal, causing pain and tenderness when the ear is touched or manipulated. A: Tophi on the pinna and ear lobe is characteristic of gout, not otitis externa. B: Dark yellow cerumen in the external auditory canal is common and not specific to otitis externa. D: Air bubbles visible in the middle ear are associated with otitis media, not otitis externa. In summary, pain on manipulation of the auricle is a key assessment finding in otitis externa, distinguishing it from other ear conditions.