ATI RN
foundations of nursing test bank Questions
Question 1 of 9
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.
Question 2 of 9
A nurse is teaching a patient about the urinarysystem. In which order will the nurse present the structures, following the flow of urine?
Correct Answer: B
Rationale: The correct order is B: Kidney, ureters, bladder, urethra. 1. Kidneys filter blood and produce urine. 2. Ureters transport urine from kidneys to bladder. 3. Bladder stores urine until expelled. 4. Urethra carries urine from bladder out of the body. Other choices are incorrect because they do not follow the anatomical flow of urine through the urinary system.
Question 3 of 9
In determining malnourishment in a patient, which assessment finding is consistent with this disorder?
Correct Answer: C
Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia). Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency. Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment. Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.
Question 4 of 9
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa?
Correct Answer: C
Rationale: The correct answer is C because African-American ethnicity and previous cesarean birth are established risk factors for placenta previa due to the potential for scarring and abnormal placental implantation. Male fetus does not influence the risk. Asian-American ethnicity and previous preterm birth are not significant risk factors. European-American ethnicity and previous spontaneous abortion are also not associated with an increased risk of placenta previa.
Question 5 of 9
A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response?
Correct Answer: C
Rationale: The correct answer is C because the severity of an anaphylactic reaction can vary greatly from one episode to another in the same patient. Anaphylactic reactions are unpredictable and can be influenced by various factors such as the amount of allergen exposure, individual immune response, underlying health conditions, and concurrent medications. Therefore, it is not possible to reliably gauge the severity of a patient's anaphylactic reaction even if it has occurred repeatedly in the past. Choice A is incorrect because the onset of symptoms alone is not a reliable predictor of the severity of the reaction. Choice B is incorrect as well because there is no set formula to predict that the reaction will be one-third more severe than the patient's last reaction. Choice D is incorrect because stating that the reaction will generally be slightly less severe than the last reaction is also not accurate or supported by evidence.
Question 6 of 9
A patient on the medical unit is dying and the nurse has determined that the familys psychosocial needs during the dying process need to be addressed. What is a cause of many patient care dilemmas at the end of life?
Correct Answer: B
Rationale: The correct answer is B: Denial of imminent death on the part of the family or the patient. This is a common cause of patient care dilemmas at the end of life because denial can lead to unrealistic expectations, difficulty in making important decisions, and inadequate planning for end-of-life care. This can result in unnecessary suffering for the patient and added stress for the family. Incorrect choices: A: Poor communication between the family and the care team can contribute to challenges in providing appropriate care but may not be the primary cause of patient care dilemmas at the end of life. C: Limited visitation opportunities for friends and family, while important for psychosocial support, may not directly cause patient care dilemmas. D: Conflict between family members can complicate decision-making processes, but it is not necessarily a primary cause of patient care dilemmas at the end of life.
Question 7 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 8 of 9
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.
Question 9 of 9
A patient with a genital herpes exacerbation has a nursing diagnosis of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (D) is not necessary for managing acute pain related to genital lesions.