ATI RN
Adult Health Med Surg Nursing Test Banks Questions
Question 1 of 9
A postpartum client who experienced a third-degree perineal laceration expresses concerns about the healing process and potential complications. What nursing intervention should be prioritized to promote optimal wound healing?
Correct Answer: D
Rationale: Third-degree perineal lacerations are significant injuries that require careful monitoring for signs of infection or wound dehiscence, which are potential complications that could hinder optimal wound healing. Signs of infection may include increased redness, warmth, swelling, pain, and purulent drainage from the wound site. Dehiscence refers to the separation of the wound edges, which can be a serious complication requiring immediate attention. By closely monitoring the incision site for these signs, the nurse can promptly intervene if any complications arise, ensuring proper healing and preventing further complications. While providing perineal care, proper application of peri-pads, and encouraging sitz baths are important for comfort and cleanliness, monitoring for complications takes priority in promoting optimal wound healing in this scenario.
Question 2 of 9
A patient presents with recurrent episodes of sudden, severe vertigo lasting hours, accompanied by nausea, vomiting, and nystagmus. Vestibular function tests demonstrate unilateral weakness. Which of the following conditions is most likely responsible for this presentation?
Correct Answer: A
Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours with nausea, vomiting, and nystagmus, along with unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is characterized by inflammation of the vestibular nerve leading to sudden onset vertigo that can last for hours to days. It is often associated with nausea, vomiting, and nystagmus. Unilateral weakness on vestibular function tests indicates dysfunction of one vestibular system. Differential diagnosis for this type of presentation includes other conditions such as Meniere's disease, BPPV, and acoustic neuroma. However, the combination of symptoms and unilateral vestibular weakness makes vestibular neuritis the most likely diagnosis in this case.
Question 3 of 9
A patient presents with acute onset of severe headache, visual disturbances, and altered mental status. Imaging reveals a tumor compressing the optic chiasm. Which of the following neurological conditions is most likely responsible for these symptoms?
Correct Answer: C
Rationale: Pituitary adenoma is the most likely neurological condition responsible for the described symptoms of acute onset severe headache, visual disturbances, and altered mental status when a tumor is found compressing the optic chiasm. Pituitary adenomas are benign tumors arising from the pituitary gland located at the base of the brain. As the tumor grows, it can compress nearby structures such as the optic chiasm, leading to visual disturbances (due to pressure on the optic nerves), severe headache (due to increased intracranial pressure), and altered mental status (due to effects on nearby brain structures).
Question 4 of 9
After formulating and delimiting the research problem, which following will be a PRIORITY action of Gloria?
Correct Answer: C
Rationale: After formulating and delimiting the research problem, the priority action would be to plan the research design of the study. This is crucial because the research design will outline the specific methods and procedures that Gloria will use to investigate the research problem and answer the research questions. Planning the research design involves determining the overall structure of the study, selecting the appropriate research methods, and outlining how data will be collected and analyzed. This step is essential for ensuring that the study is well-organized, rigorous, and will yield reliable results. Developing a solid research design early on will set a strong foundation for the rest of the research process.
Question 5 of 9
The APPROPRIATE nursing diagnosis to protect the patient from further injury is, which of the following?
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.
Question 6 of 9
A patient presents with recurrent episodes of severe headache associated with ipsilateral lacrimation, rhinorrhea, and ptosis. Symptoms are often triggered by alcohol consumption. Which of the following neurological conditions is most likely responsible for these symptoms?
Correct Answer: B
Rationale: The patient is presenting with symptoms consistent with cluster headache. Cluster headaches are characterized by recurrent episodes of severe unilateral (ipsilateral) headache accompanied by lacrimation (tearing from the eyes), rhinorrhea (runny nose), and ptosis (drooping of the eyelid). These headaches often occur in clusters over a period of weeks to months, hence the name "cluster headache."
Question 7 of 9
Ms., Sanchez is a new nursing graduate and in dire need for the hospitalization of her ailing mother She is being offered to endorse a detergent product on TV Commercial wearing a mini skirt and a plunging neckline shirt. In doing this performance Ms. Sanchez is violating the ________.
Correct Answer: C
Rationale: Ms. Sanchez is violating the code of ethics for nurses. Nurses are expected to uphold professional behavior and maintain a positive public image. Endorsing a detergent product on TV Commercial wearing a mini skirt and a plunging neckline shirt may be seen as unprofessional and contrary to the image of a nursing professional. The code of ethics for nurses requires nurses to act with integrity, maintain professional boundaries, and avoid actions that could bring discredit to the profession. By engaging in this commercial, Ms. Sanchez is not upholding the ethical standards expected of nurses.
Question 8 of 9
A pregnant woman presents with a history of recurrent pregnancy losses in the second trimester. On examination, the cervix is dilated, and uterine contractions are absent. Which of the following conditions is the most likely cause of these symptoms?
Correct Answer: D
Rationale: Incompetent cervix refers to a weakened cervix that is unable to support the weight of the growing fetus, leading to painless cervical dilation and second-trimester pregnancy loss. In this condition, the cervix may dilate prematurely without contractions, resulting in a painless cervical dilation. The history of recurrent second-trimester losses, along with cervical dilation and absence of uterine contractions in the presenting pregnant woman, are characteristic of incompetent cervix. Prompt recognition and management with cerclage placement can help prevent further pregnancy losses in women with incompetent cervix.
Question 9 of 9
A patient with a history of chronic obstructive pulmonary disease (COPD) is prescribed prednisone for an acute exacerbation. Which instruction is important for the nurse to include in patient education about prednisone therapy?
Correct Answer: B
Rationale: It is crucial for patients with COPD who are prescribed prednisone to be educated about the importance of not abruptly stopping the medication. Prednisone is a type of corticosteroid that should be tapered off gradually under the guidance of a healthcare provider to prevent potential withdrawal symptoms and adrenal insufficiency. Suddenly stopping prednisone can lead to serious adverse effects, including fatigue, weakness, joint pain, fever, dizziness, and potentially life-threatening complications. Therefore, adherence to the prescribed tapering schedule is essential to ensure the safe and effective management of COPD exacerbations with prednisone therapy.