ATI RN
test bank foundations of nursing Questions
Question 1 of 5
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 5
After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patients home care?
Correct Answer: A
Rationale: The correct answer is A: Preparation of nutritious meals and avoidance of contraindicated foods. After mastoid surgery, proper nutrition is crucial for healing and recovery. Nutritious meals support the immune system and aid in tissue repair. Avoiding contraindicated foods, such as those that may cause inflammation or interfere with medications, is essential for the patient's well-being. Choices B, C, and D are not the primary focus of home care after mastoid surgery. While rest, adaptation to hearing loss, and assistance with ambulation are important, they are secondary to ensuring proper nutrition for optimal recovery in this case.
Question 3 of 5
The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful?
Correct Answer: B
Rationale: The correct answer is B: Audiometry. Postoperative audiometry is the most appropriate assessment to determine the success of ossiculoplasty, as it evaluates the patient's hearing function and any improvements made by the surgery. Otoscopy (A) is a visual examination of the ear canal and may not provide comprehensive information on hearing. Balance testing (C) assesses equilibrium and is not directly related to the success of ossiculoplasty. Culture and sensitivity testing (D) of ear discharge is used to identify infections and would not directly indicate the success of the surgery.
Question 4 of 5
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?
Correct Answer: B
Rationale: The correct answer is B: The patient should be monitored for bone marrow depression. Carbamazepine can cause bone marrow suppression, leading to decreased production of blood cells. Monitoring blood counts is crucial to detect this adverse effect early. Choice A is incorrect as Tegretol can have serious adverse effects, including bone marrow depression. Choice C is incorrect as the main side effects of carbamazepine are related to the central nervous system, not renal dysfunction. Choice D is incorrect as medications like carbamazepine should be started at a low dose and gradually titrated up to minimize side effects.
Question 5 of 5
The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention?
Correct Answer: C
Rationale: The correct answer is C because encouraging the patient to verbalize concerns can help alleviate anxiety by allowing the patient to express emotions and fears. This intervention promotes emotional expression and provides an outlet for the patient to discuss their worries. This can lead to increased understanding and support. Incorrect answers: A: Administering antianxiety medications does not address the underlying cause of anxiety and may lead to dependency. B: Instructing the family on planning care does not directly address the patient's anxiety. D: Distracting the patient may provide temporary relief but does not address the root cause of anxiety related to lack of control over health circumstances.