ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.
Question 2 of 9
A patient has fallen several times in the pastweek when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse ismostappropriate in correcting this urinaryproblem?
Correct Answer: A
Rationale: The correct answer is A: Limit fluid and caffeine intake before bed. This recommendation addresses the issue of nocturia (frequent urination at night) by reducing the amount of urine produced before bedtime, therefore decreasing the need to get up during the night. Caffeine is a diuretic, so limiting its intake can also help reduce the frequency of urination. Choices B, C, and D do not directly address the underlying cause of nocturia and falling. Leaving the bathroom light on (choice B) may help with visibility but does not address the urinary problem. Kegel exercises (choice C) focus on pelvic floor muscles, not bladder muscles. Clearing the path to the bathroom (choice D) can prevent falls but does not address the urinary issue.
Question 3 of 9
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.
Question 4 of 9
A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Current medication regimen. In the admission assessment of a patient with AIDS, it is crucial to assess the patient's current medication regimen to ensure proper management of the condition. This includes antiretroviral therapy, prophylactic medications, and any other medications the patient may be taking to manage comorbidities. Understanding the medications the patient is currently taking allows the nurse to assess for potential drug interactions, side effects, and adherence to the treatment plan. This information is essential for providing safe and effective care for the patient. Choice B: Identification of patients support system is important but not a specific component of the comprehensive assessment for a patient with AIDS. Choice C: Immune system function is a relevant aspect in a patient with AIDS, but it is not typically assessed in the admission assessment as it requires specialized testing. Choice D: Genetic risk factors for HIV are not typically assessed in the admission assessment of a patient with AIDS as the focus is on the current condition and management
Question 5 of 9
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 6 of 9
When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?
Correct Answer: B
Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the most important risk factor for cervical cancer as it is responsible for almost all cases. Step 1: HPV infection can lead to changes in cervical cells, increasing the risk of cancer. Step 2: Early detection and vaccination against HPV can prevent cervical cancer. Step 3: Other factors like late childbearing, postmenopausal bleeding, and tobacco use may be associated with increased risk but are not as directly linked to cervical cancer development.
Question 7 of 9
A nurse administers an antimuscarinic to a patient.Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Decrease in dysuria. Antimuscarinic medications target muscarinic receptors, which are involved in the contraction of smooth muscle in the bladder. Dysuria, or painful urination, is a common symptom of overactive bladder or bladder spasms, which can be relieved by antimuscarinics. Choices B, C, and D are related to other urinary symptoms such as urgency, frequency, and prostate size, respectively, which are not directly targeted by antimuscarinics. Therefore, only a decrease in dysuria indicates therapeutic effects of the medication.
Question 8 of 9
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
Question 9 of 9
A nurse is providing an educational event to a local mens group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group?
Correct Answer: C
Rationale: The correct answer is C: African Americans. African American men have the highest incidence rate of prostate cancer among all ethnic groups. This is due to genetic and environmental factors, as well as disparities in access to healthcare. Native Americans (A), Caucasian Americans (B), and Asian Americans (D) have lower rates of prostate cancer compared to African Americans. It is important to educate the local men's group about this increased risk in African Americans to promote awareness and early detection.