ATI RN
health assessment test bank Questions
Question 1 of 9
Critique the following statement made by the nurse: "I know it may be hard, but you should do what the doctor ordered because he/she is the expert in this field.'
Correct Answer: C
Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making. The other choices are incorrect because: A: This choice focuses on bias, which is not the main issue at hand in this scenario. B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience. D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.
Question 2 of 9
What is the most important assessment for a client who has been receiving chemotherapy for several weeks?
Correct Answer: A
Rationale: The correct answer is A: Check for signs of infection. This is crucial because chemotherapy weakens the immune system, increasing the risk of infections. Signs of infection such as fever, chills, sore throat, and cough should be closely monitored to prevent serious complications. Monitoring weight (B) and nutrition (C) are important but not as critical as detecting infections promptly. Checking for skin changes (D) is also important, but it is secondary to identifying and managing infections due to the immediate threat they pose to the client's health.
Question 3 of 9
A woman comes to the clinic complaining of severe itching on her lower legs. Upon examination, the nurse notices red, scaly patches on the skin. The nurse suspects that this is:
Correct Answer: A
Rationale: The correct answer is A: Psoriasis. Psoriasis is characterized by red, scaly patches on the skin, which align with the symptoms described. Psoriasis commonly affects the lower legs and is associated with severe itching. Eczema (choice B) is characterized by red, inflamed, and itchy skin patches, but typically presents differently from psoriasis. Contact dermatitis (choice C) is a localized reaction that occurs when the skin comes into contact with an irritant or allergen, and fungal infections (choice D) typically present with itching, redness, and sometimes peeling skin, but not necessarily scaly patches like psoriasis.
Question 4 of 9
Which intervention should the nurse implement for a client who is experiencing a seizure?
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.
Question 5 of 9
What should a nurse assess for in a client with an arteriovenous fistula for hemodialysis?
Correct Answer: A
Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.
Question 6 of 9
What assessment framework provides additional modesty for clients, such as teenage girls?
Correct Answer: D
Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.
Question 7 of 9
What should be the nurse's first action when caring for a client with a traumatic amputation?
Correct Answer: A
Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications. Summary of why other choices are incorrect: B: Stopping bleeding and controlling shock can be important but not the first action. C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding. D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.
Question 8 of 9
A 59-year-old patient tells the nurse that he is in the clinic to "check up on his ulcerative colitis." He has been having "black stools" in the last 24 hours. How would the nurse document his reason for seeking care?
Correct Answer: D
Rationale: The correct answer is D because it accurately reflects the patient's chief complaint of having black stools in the last 24 hours, which is a concerning symptom suggestive of gastrointestinal bleeding. This documentation is specific and focused on the reason for seeking care, prioritizing the urgent nature of the symptom. Choice A is incorrect because it does not mention the presenting symptom of black stools. Choice B is incorrect as it does not directly state the reason for seeking care. Choice C is incorrect as it focuses on the patient's self-diagnosis of ulcerative colitis rather than the current concerning symptom of black stools.
Question 9 of 9
What is the priority action for a client who presents with symptoms of stroke?
Correct Answer: A
Rationale: The correct answer is A: Perform a CT scan. This is the priority action because it helps determine if the stroke is ischemic or hemorrhagic, guiding treatment decisions. Monitoring blood pressure (B) is important but not the priority. Administering aspirin (C) can be considered after confirming the type of stroke. Administering thrombolytics (D) is indicated for ischemic stroke but should only be done after ruling out hemorrhagic stroke with a CT scan.