ATI RN
Adult Health Med Surg Nursing Test Banks Questions
Question 1 of 9
The assessment of the patient with ingested poison must include________. I. determining the poison ingested and the amount II the time from ingestion and the signs and symptoms III. weight of the patient IV. Patient's immunization history
Correct Answer: B
Rationale: The assessment of a patient who has ingested poison must include determining the poison ingested and the amount (I), the time from ingestion and the signs and symptoms (II), as well as the weight of the patient (III). These factors are essential in evaluating the severity of the poisoning and determining the appropriate treatment plan. However, the patient's immunization history (IV) is not directly relevant to the assessment of ingested poison and thus is not essential in this context.
Question 2 of 9
Which assessment findings is INDICATIVE of the diagnosis of hypertension?
Correct Answer: D
Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (Choice A), elevation of blood cholesterol level (Choice B), and a stressful work environment (Choice C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.
Question 3 of 9
This endocrine disorder is a severe form of hypothyroidism characterized by an accumulation of mucopolysaccharide in subcutaneous and other interstitial tissues
Correct Answer: A
Rationale: Myxedema is a severe form of hypothyroidism that is characterized by the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. This condition leads to puffiness, swelling, and thickening of the skin, giving it a waxy appearance. Other symptoms of myxedema include fatigue, weight gain, cold intolerance, and hair loss. It is important to recognize and treat myxedema promptly as it can lead to serious complications such as myxedema coma, which is a life-threatening condition requiring immediate medical attention.
Question 4 of 9
The foundation of medication administration is the application for the "Rights of Medication Administration." which of the following is NOT included in these rights?
Correct Answer: D
Rationale: The "Rights of Medication Administration" include the following fundamental principles to ensure safe medication administration: right patient, right medication, right dosage, right route, right time, and right documentation. The price of the medication is not a part of these essential rights. These rights help to prevent medication errors and ensure that patients receive the correct medication in the correct way.
Question 5 of 9
A postpartum client who delivered twins expresses concerns about breastfeeding both infants simultaneously. What nursing intervention should be prioritized to address the client's concerns?
Correct Answer: A
Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.
Question 6 of 9
A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?
Correct Answer: D
Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.
Question 7 of 9
Bulimia is best defined as a /an _____.
Correct Answer: B
Rationale: Bulimia nervosa is best defined as a pathological disorder involving recurrent episodes of binge eating followed by inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting, excessive exercise, or misuse of laxatives. It is categorized as an eating disorder rather than a phobic disorder as it involves behaviors related to food consumption and body image, not just fears or phobias. Bulimia is not solely associated with starving oneself, as individuals with bulimia tend to consume large amounts of food during binge episodes. Therefore, the most accurate definition of bulimia is a pathological disorder of binging and vomiting.
Question 8 of 9
The nurse would determine that her teaching goal one the use of a decongestant nasal spray has been met when the client says ______..
Correct Answer: A
Rationale: The correct statement that indicates the teaching goal has been met is when the client says, "The spray should be used round-the-clock at equally spaced intervals." This statement shows an understanding of how to properly use the decongestant nasal spray as instructed by the nurse. Using the spray round-the-clock at equally spaced intervals helps maintain consistent relief from congestion without the risk of overuse or rebound effects. This response indicates that the client has grasped the correct usage instructions for the decongestant nasal spray, which is the goal of the teaching.
Question 9 of 9
A nurse is documenting a patient's care in the electronic health record (EHR). What principle should guide the nurse's documentation practices?
Correct Answer: B
Rationale: Documenting all care provided, including assessments and interventions, is the principle that should guide the nurse's documentation practices in the electronic health record (EHR). Comprehensive and accurate documentation is essential for ensuring continuity of care, communication among healthcare team members, and legal protection. By documenting all care provided, the nurse contributes to a complete and thorough picture of the patient's condition and treatment, facilitating safe and effective patient care. This principle also aligns with professional standards and regulatory requirements, emphasizing the importance of timely and complete documentation in the EHR.