ATI RN
foundations of nursing test bank Questions
Question 1 of 9
One of the functions of nursing care of the terminally ill is to support the patient and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support patients and their families during this process? Select all that apply.
Correct Answer: C
Rationale: Rationale: Choice C is correct because understanding the illness from the patient's perspective helps nurses provide individualized care. By empathizing with the patient's experience, nurses can tailor support to meet their specific needs. Describing personal experiences (A) may not be appropriate as it shifts the focus from the patient. Encouraging fighting for a cure (B) may not align with the patient's wishes for quality of life. Assisting with life review (D) can be beneficial but may not be a priority for all patients. Providing interventions for end-of-life closure (E) is important, but understanding the illness from the patient's perspective (C) forms the foundation for effective support.
Question 2 of 9
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.
Question 3 of 9
A nurse obtained a telephone order from a primarycare provider for a patient in pain. Which chart entry should the nurse document?
Correct Answer: C
Rationale: The correct answer is C because it includes all necessary components for a complete and accurate chart entry. The nurse documents the date and time of the order, the medication prescribed (Morphine, 2 mg, IV every 4 hours), the indication for use (incisional pain), the intended recipient (Dr. Day), the nurse's name (J. Winds), and confirmation of the read-back procedure. This entry ensures clarity, accountability, and proper communication among healthcare team members. Choice A is incorrect because it misses the recipient of the order (Dr. Day) and only includes the nurse's name in the read-back. Choice B is incorrect because it lacks the recipient of the order and the confirmation of the read-back procedure with the primary care provider. Choice D is incorrect because it does not specify the primary care provider who gave the order and misses the read-back confirmation with the provider.
Question 4 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 5 of 9
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?
Correct Answer: D
Rationale: The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned. A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described. B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo. C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.
Question 6 of 9
A laboratory finding indicatiNveU oRf SDIICN iGs oTnBe .thCatO sMhows
Correct Answer: A
Rationale: The correct answer is A: decreased fibrinogen. In disseminated intravascular coagulation (DIC), there is widespread activation of coagulation leading to consumption of clotting factors like fibrinogen, resulting in decreased levels. Platelets are usually decreased, not increased, in DIC. Hematocrit may be elevated due to hemoconcentration but not directly related to DIC. Thromboplastin time would be prolonged, not decreased, in DIC due to consumption of clotting factors.
Question 7 of 9
A 60-year-old man presents at the clinic complaining that his breasts are tender and enlarging. The patient is subsequently diagnosed with gynecomastia. The patient should be assessed for the possibility of what causative factor?
Correct Answer: B
Rationale: The correct answer is B: Medication adverse effects. Gynecomastia in a 60-year-old man is often caused by medications like spironolactone, cimetidine, and certain antipsychotics. To determine the causative factor, a thorough medication history review is crucial. Age-related physiologic changes (choice A) do not typically lead to gynecomastia in men. Poor nutrition (choice C) and fluid overload (choice D) are not common causes of gynecomastia in this context.
Question 8 of 9
A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?
Correct Answer: D
Rationale: Rationale: 1. Indispensable amino acids, also known as essential amino acids, must be obtained through the diet as the body cannot synthesize them. 2. Amino acids are the building blocks of proteins, so mentioning "indispensable amino acids" indicates understanding of essential dietary proteins. 3. Triglycerides are fats, not proteins, and not related to essential amino acids. 4. Dispensable amino acids can be synthesized by the body, so mentioning them would not indicate understanding of essential proteins.
Question 9 of 9
The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
Correct Answer: A
Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.