ATI RN
foundations of nursing test bank Questions
Question 1 of 9
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
Correct Answer: D
Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area Rationale: 1. Rubbing or scratching can further damage the already compromised skin integrity. 2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing. 3. This intervention promotes skin healing and prevents worsening of the condition. Summary: A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity. B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity. C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.
Question 2 of 9
The nurse is leading a workshop on sexual health for men. The nurse should teach participants that organic causes of erectile dysfunction include what? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Diabetes. Erectile dysfunction can be caused by organic factors, such as diabetes, which affects blood flow and nerve function. Diabetes can lead to damage of blood vessels and nerves, impacting the ability to achieve and maintain an erection. Testosterone deficiency (choice B) can also contribute to erectile dysfunction, but it is not an organic cause. Anxiety (choice C) and depression (choice D) are psychological factors that can lead to erectile dysfunction, not organic causes. Parkinsonism (choice E) can affect sexual function, but it is not a common organic cause of erectile dysfunction.
Question 3 of 9
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
Correct Answer: D
Rationale: The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer. Explanation for why the other choices are incorrect: A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer. B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast. C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.
Question 4 of 9
A nurse is caring for a group of patients. Which patient will the nurse seefirst?
Correct Answer: B
Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.
Question 5 of 9
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin. Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
Question 6 of 9
A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?
Correct Answer: B
Rationale: Step 1: Immunotherapy injections can cause allergic reactions. Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly. Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed. Step 4: This ensures patient safety and reduces the risk of severe reactions. Summary: A: Epinephrine is not typically given before immunotherapy injections. C: Therapeutic response may take longer than 3 months to show. D: Immunotherapy is usually given via subcutaneous route, not intravenous.
Question 7 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 8 of 9
Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is
Correct Answer: A
Rationale: Rationale: 1. Insulin needs change during pregnancy due to hormonal changes. 2. During the first trimester, insulin needs may decrease. 3. During the second and third trimesters, insulin needs increase. 4. Postpartum, insulin needs return to pre-pregnancy levels. Therefore, choice A is correct as insulin needs vary based on gestational stage. Choices B, C, and D are incorrect because insulin needs do not uniformly increase or decrease throughout pregnancy or due to fetal insulin production.
Question 9 of 9
A patient has just been diagnosed with breast cancer and the nurse is performing a patient interview. In assessing this patients ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask this patient?
Correct Answer: C
Rationale: The correct answer is C: Is there someone you trust to help you make treatment choices? This question assesses the patient's support system and ability to make informed decisions, which are crucial in coping with a breast cancer diagnosis. It shows the nurse's consideration for the patient's emotional well-being and involvement in the decision-making process. Choice A: What is your level of education? This question is not directly related to coping with the diagnosis of breast cancer and may not provide relevant information about the patient's ability to cope. Choice B: Are you feeling alright these days? While this question shows concern for the patient's well-being, it does not specifically address coping mechanisms or support systems. Choice D: Are you concerned about receiving this diagnosis? This question focuses on the patient's emotional reaction to the diagnosis but does not directly assess coping strategies or support systems.