ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?
Correct Answer: C
Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights. Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy. Choice B is incorrect as it disregards the patient's cultural beliefs and preferences. Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.
Question 2 of 9
A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Pain control. This is the main focus because the patient's quality of life should be prioritized, and managing pain is crucial for comfort and well-being in end-of-life care. Pain can significantly impact the patient's physical and emotional state. The other choices are incorrect because managing treatment complications (B) and administering treatments (E) may not be relevant if the tumor is inoperable and the patient has a short life expectancy. Interpretation of diagnostic tests (C) may not be necessary at this stage, and assistance with self-care (D) may not be the main priority compared to pain control.
Question 3 of 9
The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa?
Correct Answer: C
Rationale: The correct answer is C: Pain on manipulation of the auricle is characteristic of otitis externa. This is because otitis externa is an infection or inflammation of the outer ear canal, causing pain and tenderness when the ear is touched or manipulated. A: Tophi on the pinna and ear lobe is characteristic of gout, not otitis externa. B: Dark yellow cerumen in the external auditory canal is common and not specific to otitis externa. D: Air bubbles visible in the middle ear are associated with otitis media, not otitis externa. In summary, pain on manipulation of the auricle is a key assessment finding in otitis externa, distinguishing it from other ear conditions.
Question 4 of 9
A woman is considering breast reduction mammoplasty. When weighing the potential risks and benefits of this surgical procedure, the nurse should confirm that the patient is aware of what potential consequence?
Correct Answer: D
Rationale: The correct answer is D: Decreased nipple sensation. During breast reduction mammoplasty, nerves responsible for nipple sensation may be disrupted, leading to decreased sensation in the nipple area. This is an important consequence to consider as it can impact the patient's satisfaction and quality of life post-surgery. Other choices are incorrect because: A: Chronic breast pain is a potential risk of surgery but not a consequence directly related to nipple sensation. B: Unclear mammography results may occur due to breast tissue changes from surgery, but it is not a direct consequence of decreased nipple sensation. C: Increased risk of breast cancer is not a common consequence of breast reduction mammoplasty and is not directly related to nipple sensation.
Question 5 of 9
After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patients home care?
Correct Answer: A
Rationale: The correct answer is A: Preparation of nutritious meals and avoidance of contraindicated foods. After mastoid surgery, proper nutrition is crucial for healing and recovery. Nutritious meals support the immune system and aid in tissue repair. Avoiding contraindicated foods, such as those that may cause inflammation or interfere with medications, is essential for the patient's well-being. Choices B, C, and D are not the primary focus of home care after mastoid surgery. While rest, adaptation to hearing loss, and assistance with ambulation are important, they are secondary to ensuring proper nutrition for optimal recovery in this case.
Question 6 of 9
A nurse is using the explanatory model to determinethe etiology of an illness. Which questions should the nurse ask? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: What do you call your problem? In the explanatory model, this question helps the nurse understand the patient's perspective and cultural beliefs about their illness. By asking how the patient labels their illness, the nurse gains insight into the patient's understanding of the illness, which can influence their treatment adherence and outcomes. The other options are incorrect because: A: How should your sickness be treated? - This question focuses on treatment preferences rather than understanding the patient's beliefs. C: How does this illness work inside your body? - This question is more aligned with the biomedical model, seeking physiological explanations rather than patient perspectives. D: What do you fear most about your sickness? - While important for assessing emotional aspects, this question does not directly address the patient's explanatory model.
Question 7 of 9
The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address?
Correct Answer: A
Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin. Incorrect choices: B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case. C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described. D: Hypocapnia - This is low carbon dioxide levels
Question 8 of 9
A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
Correct Answer: D
Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy. 1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer. 2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy. 3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer. 4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal. 5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.
Question 9 of 9
A nurse is caring for a pregnant patient with active herpes. The teaching plan for this patient should include which of the following?
Correct Answer: A
Rationale: The correct answer is A because babies can become infected with the herpes virus if delivered vaginally. During childbirth, the virus can be passed to the infant, leading to serious health complications. This information is crucial for the patient to understand in order to make informed decisions about delivery options. Choice B is incorrect because excision of herpes lesions is not the recommended treatment during pregnancy. Treatment typically involves antiviral medications to manage symptoms and reduce the risk of transmission to the baby. Choice C is incorrect because herpes outbreaks can indeed be painful during pregnancy due to hormonal changes and a weakened immune system. Pain management strategies should be discussed as part of the teaching plan. Choice D is incorrect because pregnancy can pose a risk to the infant if the mother has active herpes. It is important to manage the condition appropriately to prevent transmission to the baby.