ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying?
Correct Answer: A
Rationale: The correct answer is A: Depression. In the context of the stages of death and dying proposed by Elisabeth Kübler-Ross, a patient exhibiting signs of loss, grief, and intense sadness is likely in the depression stage. This stage involves feelings of hopelessness, despair, and sorrow as the patient comes to terms with the reality of their situation. Denial (choice B) is characterized by a refusal to accept the diagnosis, anger (choice C) involves feelings of resentment and frustration, and resignation (choice D) signifies a sense of acceptance and peace. In this scenario, the patient's emotional state aligns most closely with depression, indicating a deep sense of sadness and mourning.
Question 2 of 9
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often?
Correct Answer: B
Rationale: The correct answer is B: At least once every 2 years. Glaucoma has a familial tendency, meaning it can run in families. Regular eye exams are crucial for early detection and treatment. Having family members undergo clinical examinations every 2 years allows for timely identification of any potential signs of glaucoma. Monthly exams (A) would be too frequent and unnecessary. Exams every 5 years (C) or 10 years (D) are too infrequent and may miss early signs of the disease. Regular biennial exams strike a balance between early detection and practicality.
Question 3 of 9
A nurse is caring for an immigrant with low income.Which information should the nurse consider when planning care for this patient?
Correct Answer: B
Rationale: The correct answer is B: There is an increased incidence of disease. Low-income immigrants often face barriers to healthcare access, leading to higher rates of undiagnosed and untreated health conditions. This information is crucial for the nurse to plan appropriate care interventions. Incorrect choices: A: Decreased frequency of morbidity is not accurate as low-income immigrants may experience higher rates of illness due to lack of resources. C: Increased level of health is unlikely in this population due to socioeconomic factors affecting health outcomes. D: Decreased mortality rate is not supported as low-income immigrants may have higher mortality rates due to limited access to healthcare.
Question 4 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 5 of 9
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement?
Correct Answer: B
Rationale: The correct answer is B: Sleep on a firm mattress. A firm mattress helps maintain proper spinal alignment, reducing pressure on the cervical spine. This promotes healing and prevents worsening of symptoms. A: Performing active ROM exercises may exacerbate symptoms and worsen the condition. C: Applying cool compresses may provide temporary relief but does not address the underlying issue of spinal alignment. D: Wearing a cervical collar for extended periods can weaken neck muscles and hinder natural healing processes. In summary, sleeping on a firm mattress is the most appropriate conservative measure as it supports proper spinal alignment.
Question 6 of 9
A child is undergoing testing for food allergies after experiencing unexplained signs and symptoms of hypersensitivity. What food items would the nurse inform the parents are common allergens?
Correct Answer: C
Rationale: The correct answer is C: Eggs and wheat. This is because eggs and wheat are common food allergens in children. Eggs contain proteins that can trigger allergic reactions, while wheat contains gluten, a common allergen. Citrus fruits and rice (choice A) are not common allergens. Root vegetables and tomatoes (choice B) are also less likely to cause allergies. Hard cheeses and vegetable oils (choice D) are not commonly associated with food allergies in children. Therefore, informing the parents about eggs and wheat as common allergens is crucial for the child's testing and management of food allergies.
Question 7 of 9
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby. Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.
Question 8 of 9
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
Question 9 of 9
The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patients health education?
Correct Answer: C
Rationale: The correct answer is C: The need to perform thorough hand hygiene before handling the prosthesis. This is crucial to prevent infection. By washing hands thoroughly, the patient reduces the risk of introducing harmful bacteria or pathogens to the prosthesis, which could lead to infections or other complications. Incorrect Choices: A: The need to limit exposure to bright light - This is not directly related to caring for an ocular prosthesis. B: The need to maintain a low Fowlers position when removing the prosthesis - Positioning is not typically a concern when caring for an ocular prosthesis. D: The need to apply antiviral ointment to the prosthesis daily - Antiviral ointment is not a standard part of ocular prosthesis care unless specifically prescribed by a healthcare provider for a particular reason.