Patient Ximena sought referral to an abort ion clinic from the nurse. She reasons out that her pregnancy a burden to her work and daily routines. What should be the BEST RESPONSE of the nurse?

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Adult Health Nursing Test Bank Questions

Question 1 of 9

Patient Ximena sought referral to an abort ion clinic from the nurse. She reasons out that her pregnancy a burden to her work and daily routines. What should be the BEST RESPONSE of the nurse?

Correct Answer: A

Rationale: The correct response is A because it addresses the patient's concerns about potential discrimination. This shows empathy and understanding towards the patient's emotional well-being. Choices B, C, and D are incorrect because they do not directly address the patient's reasons for seeking an abortion. Choice B imposes moral and legal judgments, which can be insensitive. Choice C is not relevant to the patient's stated reason. Choice D imposes religious beliefs, which may not align with the patient's own beliefs.

Question 2 of 9

A patient presents with acute onset of shoulder pain and limited range of motion after a fall onto an outstretched hand. Physical examination reveals tenderness over the greater tuberosity of the humerus and pain with passive abduction and external rotation of the shoulder. Which of the following conditions is most likely?

Correct Answer: A

Rationale: The correct answer is A: Rotator cuff tear. The presentation of acute shoulder pain and limited range of motion after a fall onto an outstretched hand, along with tenderness over the greater tuberosity and pain with passive abduction and external rotation, is classic for a rotator cuff tear. The mechanism of injury and physical exam findings are consistent with this condition. B: Glenohumeral dislocation typically presents with a visibly deformed shoulder and loss of normal shoulder contour. C: Acromioclavicular joint separation would present with tenderness over the AC joint rather than the greater tuberosity, and typically involves a history of direct trauma to the shoulder. D: Proximal humerus fracture would present with more diffuse shoulder pain and swelling, and not specific tenderness over the greater tuberosity.

Question 3 of 9

A woman in active labor demonstrates signs of prolonged second stage, characterized by ineffective pushing efforts and slow fetal descent. What maternal condition should the nurse assess for that may contribute to this abnormal labor pattern?

Correct Answer: B

Rationale: When a woman in active labor exhibits signs of prolonged second stage, such as ineffective pushing efforts and slow fetal descent, one of the maternal conditions that should be considered is pelvic floor dysfunction. The pelvic floor muscles play a crucial role in supporting the uterus, bladder, and rectum. If these muscles are weak or dysfunctional, it can lead to difficulty in pushing effectively and impede the descent of the fetus through the birth canal. This can result in prolonged labor and increase the risk of complications for both the mother and the baby. Therefore, assessing for pelvic floor dysfunction is important in addressing the abnormal labor pattern and providing appropriate interventions to support the progress of labor.

Question 4 of 9

A pregnant woman presents with fever, chills, and abdominal pain localized to the right upper quadrant. On examination, she has tenderness in the right upper abdomen and a positive Murphy's sign. Which of the following conditions is the most likely cause of these symptoms?

Correct Answer: C

Rationale: The scenario described in the question is consistent with acute cholecystitis, which is inflammation of the gallbladder usually caused by an impacted gallstone in the cystic duct. The key clinical features of acute cholecystitis include fever, chills, right upper quadrant abdominal pain (which can be localized to the right upper quadrant), tenderness in the right upper abdomen, and a positive Murphy's sign (pain and inspiratory arrest upon palpation of the right upper quadrant). This condition is more common in pregnant women due to hormonal changes that can lead to gallstone formation and subsequent inflammation of the gallbladder. Ectopic pregnancy, pelvic inflammatory disease, and ovarian torsion typically present with different clinical features compared to those described in acute cholecystitis.

Question 5 of 9

A postpartum client who delivered via cesarean section expresses discomfort when ambulating and performing activities of daily living. What nursing intervention should be prioritized to promote optimal recovery?

Correct Answer: A

Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.

Question 6 of 9

To begin your discussion, you explain to her that the endocrine glands include, which of the following?

Correct Answer: A

Rationale: The correct answer is A because it includes all the major endocrine glands: pituitary, thyroid, parathyroid, adrenals, pancreatic islets, and hypothalamus. The pituitary gland is known as the "master gland" as it controls other endocrine glands. The thyroid gland regulates metabolism, while the parathyroid glands regulate calcium levels. The adrenal glands produce hormones involved in stress response. Pancreatic islets produce insulin and glucagon. The hypothalamus plays a key role in hormone regulation. Choice B is incorrect because it includes ovaries and testes, which are not endocrine glands. Choice C is incorrect because it omits the hypothalamus. Choice D is incorrect because it includes ovaries and testes which are not endocrine glands.

Question 7 of 9

The nurse is aware that which occurrence in the patient 's health history suggests the diagnosis of GBS?

Correct Answer: A

Rationale: The correct answer is A because a viral illness few weeks before can trigger Guillain-Barre Syndrome (GBS) due to the body's immune response attacking the peripheral nerves. Encephalitis (B), severe bacterial infection (C), and meningitis (D) are not directly linked to GBS pathophysiology. Viral infections are known to precede GBS development, making choice A the most appropriate option.

Question 8 of 9

When a person vaccinated with a Covid-19 vaccine produces antibodies to the disease, the immunity is termed:

Correct Answer: A

Rationale: The correct answer is A: Active artificial immunity. This is because the person's immune system is actively stimulated by the vaccine to produce antibodies against Covid-19. It is considered artificial because it is acquired through vaccination rather than natural exposure to the disease. B: Active natural immunity is incorrect because it refers to immunity acquired through natural exposure to the disease. C: Passive natural immunity is incorrect because it refers to temporary immunity passed from mother to baby through breast milk or placenta. D: Passive artificial immunity is incorrect because it refers to receiving pre-formed antibodies, such as through an injection of antibodies rather than the body producing them itself.

Question 9 of 9

The physician prescribes decongestant intranasal spray. The nurse instructs the client on the proper use of the spray. Which of the following procedures is the CORRECT method?

Correct Answer: D

Rationale: The correct answer is D: Tilt the head slightly forward and angle the bottle toward the side of the nostril. This method allows for proper administration of the spray into the nasal passage, ensuring effective delivery of the medication. Tilted head helps direct the spray towards the nasal cavity without causing discomfort or leakage. It also helps prevent the medication from dripping down the back of the throat. Choices A, B, and C are incorrect: A: Finishing instillation in one nostril before moving to the other can lead to uneven distribution of medication and reduced effectiveness. B: Inhaling quickly may cause irritation and discomfort to the mucous membranes due to the forceful intake of the spray. C: Blowing the nose after spraying can expel the medication before it has a chance to be absorbed, decreasing its efficacy.

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