ATI RN
health assessment exam 2 test bank Questions
Question 1 of 5
During an interview with a patient, at which distance would the nurse expect that most of the interview will take place?
Correct Answer: B
Rationale: The correct answer is B: 1.5 m. This distance is known as the personal distance in communication, where most interviews take place. Personal distance allows for a comfortable level of interaction without invading personal space. Choice A (1 m) is too close and may make the patient uncomfortable. Choice C (2 m) is too far for an intimate interview setting. Choice D (3 m) is too distant and may lead to a lack of connection and understanding during the interview. Overall, B is the best choice for a nurse-patient interview to ensure a respectful and effective conversation.
Question 2 of 5
A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train.' What is the best way for the nurse to communicate with this patient?
Correct Answer: D
Rationale: The correct answer is D because the patient is showing signs of expressive aphasia, where they have difficulty with verbal expression. By supporting his efforts to communicate and using pantomime and gestures, the nurse can help bridge the communication gap and facilitate understanding. This approach acknowledges the patient's drive to communicate and helps him convey his thoughts effectively. Option A is incorrect because although the patient may understand, the nurse needs to adapt the communication method to support the patient's expressive difficulties. Option B is incorrect as abandoning communication efforts would be detrimental to the patient's well-being and recovery. Option C is incorrect as the patient's ability to read and write may also be impaired due to the stroke, making this method less effective than using gestures and pantomime.
Question 3 of 5
A 23-year-old patient is in the clinic and appears anxious. Her speech is rapid. She is fidgety and in constant motion. Which of the following questions or statements would be most appropriate for the nurse to use in this situation to assess attention span?
Correct Answer: D
Rationale: The correct answer is D because it involves a specific and observable task that assesses attention span. By asking the patient to perform a physical action that requires focus and coordination, the nurse can directly evaluate the patient's ability to follow instructions and maintain attention. This task also helps to assess motor skills and coordination, which can be affected in certain conditions associated with anxiety and restlessness. Choices A, B, and C are incorrect because they do not directly assess attention span. Choice A focuses on emotions and behavior rather than attention. Choice B assesses memory recall rather than attention span. Choice C tests comprehension and interpretation skills related to a phrase, but it does not evaluate attention span directly.
Question 4 of 5
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse would expect to find which of the following?
Correct Answer: D
Rationale: The correct answer is D: Clubbing of the nails. Clubbing is a physical finding associated with chronic respiratory conditions like emphysema and bronchitis. It is characterized by the softening of the nail bed and the loss of the normal angle between the nail and the nail bed. This occurs due to chronic hypoxia and can be a sign of advanced lung disease. Anasarca (choice A) is generalized edema, not specific to respiratory conditions. Scleroderma (choice B) is a connective tissue disorder affecting the skin and other organs, not directly related to respiratory conditions. Pedal erythema (choice C) refers to redness of the feet and is not a typical finding in emphysema or bronchitis.
Question 5 of 5
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.