ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?
Correct Answer: A
Rationale: The correct answer is A: Uplifting memories. When assessing hope in a terminally ill patient, identifying uplifting memories can foster hope by providing emotional support, positive experiences, and a sense of purpose. Memories can inspire optimism and comfort in difficult times. B: Ignoring negative outcomes is incorrect as it does not address the patient's emotional needs or promote coping strategies. C: Envisioning one specific outcome is incorrect because hope should encompass a range of possibilities, not just one specific outcome. D: Avoiding an actual or potential threat is incorrect as it focuses on avoidance rather than on promoting positive emotions and psychological well-being.
Question 2 of 9
One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?
Correct Answer: A
Rationale: The correct answer is A: Uplifting memories. When assessing hope in a terminally ill patient, identifying uplifting memories can foster hope by providing emotional support, positive experiences, and a sense of purpose. Memories can inspire optimism and comfort in difficult times. B: Ignoring negative outcomes is incorrect as it does not address the patient's emotional needs or promote coping strategies. C: Envisioning one specific outcome is incorrect because hope should encompass a range of possibilities, not just one specific outcome. D: Avoiding an actual or potential threat is incorrect as it focuses on avoidance rather than on promoting positive emotions and psychological well-being.
Question 3 of 9
A nurse is caring for a male patient with urinaryretention. Which action should the nurse takefirst?
Correct Answer: C
Rationale: The correct answer is C: Assist to a standing position. This action helps utilize gravity to aid in emptying the bladder and may help the patient void without the need for invasive measures like catheterization or medications. It is a non-invasive and natural approach to promote urination. Limiting fluid intake (A) could worsen the situation by concentrating urine and worsening retention. Inserting a urinary catheter (B) should be considered only if other measures fail. Asking for a diuretic medication (D) does not address the immediate need for bladder emptying and may not be necessary if the patient can void naturally.
Question 4 of 9
The nurse is providing care for a patient who has experienced a type I hypersensitivity reaction. What condition is an example of such a reaction?
Correct Answer: A
Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.
Question 5 of 9
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?
Correct Answer: D
Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.
Question 6 of 9
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to keep his or her feeding area clean. This is the most appropriate independent nursing action as it promotes hygiene and reduces the risk of infection. Keeping the feeding area clean is essential in preventing complications in a patient with malnutrition. Rationales for why the other choices are incorrect: A: Firmly redirect the patient's head when feeding - This is incorrect because forceful redirection can cause distress and discomfort to the patient, potentially leading to aspiration or choking. B: Administer phenothiazines after each meal as ordered - This is incorrect as phenothiazines are not typically used for malnutrition treatment and should not be administered without a specific indication. D: Apply deep, gentle pressure around the patient's mouth to aid swallowing - This is incorrect because applying pressure around the mouth can pose a choking hazard and should not be done without proper assessment and intervention by a speech therapist or swallowing specialist.
Question 7 of 9
Massage around the feces and work down to remove.
Correct Answer: A
Rationale: The correct order for the massage is to start around the feces (4), then work downwards (1), followed by moving towards the sides (5), then back to the top (2), continuing to the sides again (3), and finally finishing at the top (6). This sequence ensures a thorough and effective massage process. Other choices have different orders that do not follow the logical flow of massaging around the feces and working down as specified in the question.
Question 8 of 9
A patient is brought to the emergency department (ED) in a state of anaphylaxis. What is the ED nurses priority for care?
Correct Answer: B
Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.
Question 9 of 9
The nurse asks a patient where the pain is, andthe patient responds by pointing to the area of pain. Which form of communication did the patient use?
Correct Answer: B
Rationale: The correct answer is B: Nonverbal. The patient used nonverbal communication by pointing to the area of pain, which is a form of expressing information without words. This choice is correct because pointing is a nonverbal gesture that conveys a specific message. Verbal communication (A) involves spoken or written words, which were not used in this scenario. Intonation (C) refers to the rise and fall of the voice in speech, which was not demonstrated by the patient. Vocabulary (D) is the range of words known or used by a person, but the patient did not use words to communicate in this situation. In summary, the patient used nonverbal communication through pointing, making choice B the correct answer.