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
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?
Correct Answer: B
Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.
Question 3 of 9
A patient who has had a lumpectomy calls the clinic to talk to the nurse. The patient tells the nurse that she has developed a tender area on her breast that is red and warm and looks like someone drew a line with a red marker. What would the nurse suspect is the womans problem?
Correct Answer: A
Rationale: The correct answer is A: Mondor disease. This condition presents as a superficial thrombophlebitis of the breast veins, causing a tender, red, warm, cord-like area resembling a red line. This is typically benign and self-limiting. B: Deep vein thrombosis (DVT) of the breast is unlikely as it typically involves deeper veins in the extremities. C: Recurrent malignancy is less likely as the symptoms described are more indicative of a benign condition like Mondor disease. D: An area of fat necrosis is also less likely as it usually presents as a painless, firm lump rather than a red, warm, tender area.
Question 4 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 5 of 9
A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increase the likelihood of successful therapy?
Correct Answer: B
Rationale: The correct answer is B: Addressing possible barriers to adherence. This is crucial because adherence to the antiretroviral drug regimen is key for successful therapy in HIV patients. By identifying and addressing barriers such as medication side effects, cost, or forgetfulness, nurses can help patients stay on track with their treatment. Other choices are incorrect: A: Promoting complementary therapies is not the priority in initiating antiretroviral therapy. Adherence to the prescribed regimen is more critical. C: Educating about the pathophysiology of HIV is important, but it may not directly impact the success of the therapy as much as addressing adherence barriers. D: While follow-up blood work is necessary, it is not as immediate and impactful as addressing adherence barriers at the beginning of therapy.
Question 6 of 9
The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient?
Correct Answer: A
Rationale: The correct answer is A: Leukopenia. Taxol and Paraplatin are known to cause bone marrow suppression, leading to decreased white blood cell counts. Leukopenia can increase the patient's risk of infection, so monitoring for signs of infection is crucial. Metabolic acidosis, hyperphosphatemia, and respiratory alkalosis are not typically associated with Taxol and Paraplatin chemotherapy.
Question 7 of 9
One aspect of the nurses comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would the nurse identify as a hope-fostering category?
Correct Answer: A
Rationale: The correct answer is A: Uplifting memories. When assessing hope in a terminally ill patient, identifying uplifting memories can foster hope by providing emotional support, positive experiences, and a sense of purpose. Memories can inspire optimism and comfort in difficult times. B: Ignoring negative outcomes is incorrect as it does not address the patient's emotional needs or promote coping strategies. C: Envisioning one specific outcome is incorrect because hope should encompass a range of possibilities, not just one specific outcome. D: Avoiding an actual or potential threat is incorrect as it focuses on avoidance rather than on promoting positive emotions and psychological well-being.
Question 8 of 9
A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntingtons Disease Society of America. What kind of help can this patient and family receive from this organization? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Information about this disease. The Huntington's Disease Society of America provides valuable resources such as educational materials, support groups, and updates on research. This information can help patients and families understand the disease better and navigate available treatment options. Referrals, public education, individual assessments, and appraisals of research studies are not typically services provided directly by the organization, making them incorrect choices in this context.
Question 9 of 9
A patient taking magnesium sulfate has a respiratory rate of 10 breaths per minute. In addition to discontinuing the medication, which action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Administer calcium gluconate. Magnesium sulfate can cause respiratory depression, leading to a low respiratory rate. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on the neuromuscular junction. Administering calcium gluconate helps reverse the respiratory depression caused by magnesium sulfate. Increasing IV fluids (Choice A) is not directly related to treating respiratory depression. Vigorously stimulating the patient (Choice C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (Choice D) may not be effective in addressing the underlying cause of respiratory depression due to magnesium sulfate toxicity.