ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient?
Correct Answer: C
Rationale: The correct answer is C: Autoimmune disorders. Raynaud's phenomenon is often associated with autoimmune conditions, such as systemic lupus erythematosus or scleroderma. Testing for autoimmune disorders may involve blood tests to check for specific antibodies or inflammatory markers. Hyperglycemia (A) is high blood sugar levels, not directly related to Raynaud's. Hyperlipidemia (B) is high levels of fats in the blood, not typically associated with Raynaud's. Coronary artery disease (D) involves the narrowing of the arteries that supply blood to the heart, which is not directly related to Raynaud's phenomenon.
Question 2 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JD) with the head of the patient's bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JD) indicates increased pressure in the right atrium. Step 2: When the head of the bed is elevated, gravity helps blood return to the right side of the heart. Step 3: If JD is present with head elevation, it suggests that the right atrial pressure is elevated. Step 4: Elevated right atrial pressure often indicates heart failure or fluid overload. Step 5: Therefore, the correct answer is C: Increased right atrial pressure. Summary: A: Decreased fluid volume is incorrect because JD suggests fluid overload, not decreased volume. B: Jugular vein atherosclerosis is incorrect as JD is not typically associated with atherosclerosis. D: Incompetent jugular vein valves is incorrect as JD is more likely due to increased pressure than valve incompetence.
Question 3 of 5
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
Correct Answer: A
Rationale: Step 1: Assess for anxiety - The client's lack of comprehension, forgetfulness, and repetitive questions indicate potential anxiety affecting their ability to process information. Step 2: Identify potential anxiety cues - Look for signs such as restlessness, increased heart rate, or verbal expressions of worry. Step 3: Address anxiety first - Once anxiety is identified, the nurse can provide appropriate interventions to help the client better understand and retain the information. Step 4: Provide supportive measures - After addressing anxiety, breaking information into smaller bits, giving written information, and reviewing the information can be helpful, but addressing anxiety is key to enhancing the client's ability to comprehend and retain information.
Question 4 of 5
An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in discharge teaching?
Correct Answer: C
Rationale: The correct answer is C: Need for frequent laboratory blood testing. For a patient on warfarin with a mechanical valve, regular monitoring of the international normalized ratio (INR) is essential to ensure the medication's effectiveness and prevent complications like clotting or bleeding. Incorrect choices: A - Aspirin is not recommended with warfarin due to increased bleeding risk. B - Knowing how to take radial pulse is not directly related to warfarin therapy. D - Avoiding physical activity is not necessary; instead, patients should engage in regular, moderate exercise unless advised otherwise by a healthcare provider.
Question 5 of 5
A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s compensatory mechanisms?
Correct Answer: A
Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client has metabolic acidosis indicated by a low pH and low HCO3 levels. The PaCO2 is low, which is not expected in metabolic acidosis. Therefore, the respiratory system is compensating by decreasing PaCO2 through increased rate and depth of respirations to help normalize the pH. Increased urinary output (choice B) and increased thirst and hunger (choice C) are not directly related to compensatory mechanisms for acid-base imbalances. Increased release of acids from the kidneys (choice D) would exacerbate the acidosis rather than compensate for it.