ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction?
Correct Answer: B
Rationale: The correct answer is B because chest pain lasting longer than 30 minutes is a common characteristic of an acute myocardial infarction (heart attack). This prolonged duration indicates cardiac tissue damage. Choices A, C, and D are incorrect. Choice A, pain increasing with deep breathing, is more indicative of musculoskeletal pain. Choice C, pain relieved by nitroglycerin, is suggestive of angina rather than a heart attack. Choice D, reproducible pain with arm movement, is more consistent with musculoskeletal or nerve-related pain rather than a heart attack.
Question 2 of 5
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
Correct Answer: A
Rationale: Step 1: Assess for anxiety - The client's lack of comprehension, forgetfulness, and repetitive questions indicate potential anxiety affecting their ability to process information. Step 2: Identify potential anxiety cues - Look for signs such as restlessness, increased heart rate, or verbal expressions of worry. Step 3: Address anxiety first - Once anxiety is identified, the nurse can provide appropriate interventions to help the client better understand and retain the information. Step 4: Provide supportive measures - After addressing anxiety, breaking information into smaller bits, giving written information, and reviewing the information can be helpful, but addressing anxiety is key to enhancing the client's ability to comprehend and retain information.
Question 3 of 5
An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in discharge teaching?
Correct Answer: C
Rationale: The correct answer is C: Need for frequent laboratory blood testing. For a patient on warfarin with a mechanical valve, regular monitoring of the international normalized ratio (INR) is essential to ensure the medication's effectiveness and prevent complications like clotting or bleeding. Incorrect choices: A - Aspirin is not recommended with warfarin due to increased bleeding risk. B - Knowing how to take radial pulse is not directly related to warfarin therapy. D - Avoiding physical activity is not necessary; instead, patients should engage in regular, moderate exercise unless advised otherwise by a healthcare provider.
Question 4 of 5
A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s compensatory mechanisms?
Correct Answer: A
Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client has metabolic acidosis indicated by a low pH and low HCO3 levels. The PaCO2 is low, which is not expected in metabolic acidosis. Therefore, the respiratory system is compensating by decreasing PaCO2 through increased rate and depth of respirations to help normalize the pH. Increased urinary output (choice B) and increased thirst and hunger (choice C) are not directly related to compensatory mechanisms for acid-base imbalances. Increased release of acids from the kidneys (choice D) would exacerbate the acidosis rather than compensate for it.
Question 5 of 5
The nurse understands that which type of immunity is the longest acting?
Correct Answer: C
Rationale: The correct answer is C: Natural active immunity. This type of immunity is the longest acting because it results from the body's exposure to a pathogen, leading to the production of memory cells that provide long-lasting protection. Natural active immunity involves the immune system responding to an actual infection or exposure to a pathogen, which triggers the production of antibodies and memory cells for future protection. In contrast, artificial active immunity (choice A) involves vaccines, which may require booster shots for long-lasting protection. Inflammatory response (choice B) is not a type of immunity but rather a non-specific defense mechanism against pathogens. Natural passive immunity (choice D) is short-lived and acquired from maternal antibodies, providing temporary protection.