ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram?(Select the one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A. Hypertension alone may not directly warrant an electrocardiogram (ECG) as it primarily indicates high blood pressure. However, fatigue despite adequate rest, indigestion, and abdominal pain can be symptoms of underlying cardiac issues that require an ECG for further evaluation. Fatigue can be a sign of heart problems affecting oxygen delivery, while indigestion and abdominal pain can be symptoms of a heart attack or other cardiac conditions. Requesting an ECG based on these symptoms can help identify potential cardiac issues early on.
Question 2 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: The correct answer is B: Place a patient with altered consciousness in a side-lying position. This position helps prevent aspiration by reducing the risk of regurgitated material entering the airway. Patients with altered consciousness are at higher risk of aspiration due to impaired protective airway reflexes. Placing them in a side-lying position helps maintain an open airway and facilitates drainage of secretions. Incorrect choices: A: Turning and repositioning an immobile patient every 2 hours is important for preventing pressure ulcers, not aspiration. C: Inserting a nasogastric tube for feeding does not directly prevent aspiration; it is a method of providing nutrition. D: Monitoring respiratory symptoms in an immunosuppressed patient is important for detecting infections but does not directly prevent aspiration.
Question 3 of 5
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Perform a test focused on a neurologic examination. The client's symptoms indicate potential neurological issues, such as vision difficulties and constant nasal drainage, which could be related to nerve damage from the nasal fracture. By performing a neurologic examination, the nurse can assess for any nerve involvement and determine the extent of the injury. This action is crucial in identifying any neurological complications and guiding appropriate treatment. Summary: A: Collecting nasal drainage does not address the client's neurological symptoms. B: Encouraging the client to blow his or her nose could exacerbate the nasal fracture and is not relevant to the neurological symptoms. D: Palpating the nose, face, and neck may help assess the extent of the fracture but does not address the neurological symptoms reported by the client.
Question 4 of 5
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Puffy face and swollen eyelids can indicate a potential airway obstruction, which is a medical emergency. Notifying the Rapid Response Team ensures prompt intervention and appropriate management. Assessing oxygen saturation (A) may be important but addressing the potential obstruction takes priority. Oxygenating with a bag-valve-mask (C) may worsen the obstruction. Palpating the skin of the upper chest (D) is not directly related to addressing the potential airway issue.
Question 5 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.