ATI RN
test bank foundations of nursing Questions
Question 1 of 5
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?
Correct Answer: D
Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.
Question 2 of 5
A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy?
Correct Answer: D
Rationale: The correct answer is D because patients with lower health literacy, such as those with a high-school diploma, may struggle to understand complex health information. The nurse should assess this patient closely to ensure they comprehend and can follow instructions. Patients with higher education levels (college degree) may have better health literacy skills. Age alone (35 or 68 years old) does not determine health literacy level. It is essential to focus on the patient's educational background to assess their health literacy effectively.
Question 3 of 5
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 4 of 5
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 5
A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
Correct Answer: B
Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation. Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling. Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling. Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.
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