ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find?
Correct Answer: A
Rationale: Step-by-step rationale for why A is correct: 1. Retinal detachment causes traction on the retina. 2. Traction on the retina can stimulate photoreceptors. 3. Stimulation of photoreceptors can lead to perception of flashing lights. 4. Therefore, the characteristic symptom of retinal detachment is flashing lights in the visual field. Summary: B: Sudden eye pain is not a characteristic symptom of retinal detachment. C: Loss of color vision is not typically associated with retinal detachment. D: Colored halos around lights are more indicative of conditions like glaucoma or corneal edema, not retinal detachment.
Question 2 of 9
A nurse is watching a nursing assistive personnel(NAP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up?
Correct Answer: D
Rationale: The correct answer is D because setting the scanner to female is incorrect for a patient who has had a hysterectomy as they do not have a uterus. This could lead to inaccurate results. Palpating the symphysis pubis (A) ensures proper positioning, wiping the scanner head with alcohol (B) maintains infection control, and applying gel (C) facilitates sound wave transmission.
Question 3 of 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 4 of 9
A patient presents to the emergency department with paraphimosis. The physician is able to compress the glans and manually reduce the edema. Once the inflammation and edema subside, what is usually indicated?
Correct Answer: B
Rationale: The correct answer is B: Circumcision. Paraphimosis occurs when the foreskin is retracted behind the glans and cannot be returned to its original position. Once the inflammation and edema subside, circumcision is typically indicated to prevent recurrence. This procedure removes the foreskin, reducing the risk of future paraphimosis episodes. Needle aspiration of the corpus cavernosum (A) is not indicated for paraphimosis. Abstinence from sexual activity for 6 weeks (C) is not a standard treatment for paraphimosis. Administration of vardenafil (D) is used for erectile dysfunction and not indicated for paraphimosis.
Question 5 of 9
Traditionally, nurses have been involved with tertiary cancer prevention. However, an increasing emphasis is being placed on both primary and secondary prevention. What would be an example of primary prevention?
Correct Answer: C
Rationale: The correct answer is C: Teaching patients to wear sunscreen, which is an example of primary prevention. Primary prevention aims to prevent the occurrence of a disease before it occurs by addressing risk factors. In this case, teaching patients to wear sunscreen helps prevent skin cancer by reducing exposure to harmful UV rays. Yearly Pap tests (A) are a secondary prevention measure for cervical cancer, detecting precancerous changes. Testicular self-examination (B) is a form of secondary prevention for testicular cancer, aiming to detect any abnormalities early. Screening mammograms (D) are also a secondary prevention measure for breast cancer, detecting tumors at an early stage.
Question 6 of 9
A patient has just died following urosepsis that progressed to septic shock. The patients spouse says, I knew this was coming, but I feel so numb and hollow inside. The nurse should know that these statements are characteristic of what?
Correct Answer: A
Rationale: The correct answer is A: Complicated grief and mourning. This is characterized by a sense of emotional numbness and feeling hollow inside, which the patient's spouse is experiencing after the patient's death. Complicated grief involves intense and prolonged mourning that may interfere with daily functioning. Other choices are incorrect because: B: Uncomplicated grief and mourning typically involves a range of emotions, including sadness and sorrow, but not the profound numbness and emptiness described. C: Depression stage of dying refers to a stage in the Kubler-Ross model, but the patient's spouse is not the one dying, so this does not apply. D: Acceptance stage of dying involves coming to terms with one's impending death, not the aftermath of losing a loved one to sepsis.
Question 7 of 9
Which action indicates the nurse is meeting aprimary goal of cultural competent care for patients?
Correct Answer: C
Rationale: The correct answer is C because providing individualized care is a fundamental aspect of cultural competence. This means tailoring care to meet the unique cultural, social, and personal needs of each patient. It involves understanding and respecting a patient's beliefs, values, and practices. Explanation: A. Providing care to transgender patients is important, but it is not the primary goal of cultural competence. B. Restoring relationships is beneficial but may not directly address cultural competence. D. Providing care to surgical patients is a common nursing duty but does not specifically relate to cultural competence.
Question 8 of 9
In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient?
Correct Answer: B
Rationale: The correct answer is B: Saturated fat should be limited to less than 7% of total calories. This is because limiting saturated fat intake is crucial in managing type 1 diabetes to reduce the risk of cardiovascular diseases. Saturated fats can worsen insulin resistance and lead to complications. Choice A is incorrect as diabetic management involves more than just insulin. Choice C is incorrect because nonnutritive sweeteners should be used in moderation due to potential side effects. Choice D is incorrect as individuals with diabetes should aim to keep cholesterol intake low to prevent heart problems.
Question 9 of 9
The nurse is planning the care of a patient who has a diagnosis of atopic dermatitis, which commonly affects both of her hands and forearms. What risk nursing diagnosis should the nurse include in the patients care plan?
Correct Answer: D
Rationale: The correct answer is D: Risk for Self-Care Deficit Related to Skin Lesions. Patients with atopic dermatitis may experience difficulty performing self-care tasks due to pain, itching, and limitations in hand mobility caused by skin lesions. This diagnosis addresses the potential challenges the patient may face in maintaining personal hygiene and managing their skin condition. Explanation for why other choices are incorrect: A: Risk for Disturbed Body Image Related to Skin Lesions - While atopic dermatitis may impact body image, the priority in this case is the patient's ability to perform self-care. B: Risk for Disuse Syndrome Related to Dermatitis - Disuse syndrome is not typically associated with atopic dermatitis. C: Risk for Ineffective Role Performance Related to Dermatitis - This diagnosis focuses on the patient's ability to fulfill their roles, which may not be directly impacted by atopic dermatitis.