ATI RN
health assessment test bank jarvis Questions
Question 1 of 5
The nurse is assessing orientation in a 79-year-old patient. Which of the following responses would lead the nurse to conclude that this patient is oriented?
Correct Answer: D
Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains. Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.
Question 2 of 5
A patient of African descent is in the critical care unit to be monitored for shock after an accident. What skin characteristics would the nurse expect to find in this patient?
Correct Answer: C
Rationale: The correct answer is C: Ashen, grey, or dull. In patients of African descent, skin characteristics may appear ashen, grey, or dull when experiencing shock due to reduced blood flow and oxygen delivery. This is because the skin may appear pale or lacking in color due to decreased perfusion. The other choices are incorrect because: A: Ruddy blue - Ruddy blue skin color is not typically associated with shock in patients of African descent. B: Generalized pallor - Generalized pallor refers to an overall paleness of the skin, which is not commonly seen in patients of African descent during shock. D: Patchy areas of pallor - Patchy areas of pallor suggest uneven skin color changes, which are not typically characteristic of shock in patients of African descent.
Question 3 of 5
A nurse is assessing a patient's breath sounds and notes that the patient has a wheeze. This is most likely indicative of:
Correct Answer: B
Rationale: The correct answer is B: Asthma. Wheezing is a high-pitched whistling sound heard during expiration caused by narrowed airways in conditions like asthma. Pneumonia (A) typically presents with crackles, not wheezes. Pulmonary embolism (C) may cause sudden chest pain and shortness of breath but not wheezing. Pleural effusion (D) results in decreased breath sounds, not wheezes.
Question 4 of 5
A nurse is teaching a patient about managing diabetes. Which of the following actions would the nurse emphasize as most important in preventing complications from diabetes?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Monitoring blood glucose levels regularly allows for timely adjustments in treatment. 2. It helps in preventing hypoglycemia or hyperglycemia complications. 3. Enables the patient to understand how their lifestyle choices impact their blood sugar levels. 4. Empowers the patient to make informed decisions regarding their diabetes management. Summary of why the other choices are incorrect: B: Limiting physical activity can lead to complications like obesity and decreased insulin sensitivity. C: Diet should focus on balanced nutrition, not just low-fat or high-protein, to manage diabetes effectively. D: Taking insulin regardless of blood sugar levels can result in hypoglycemia or poor blood sugar control.
Question 5 of 5
A nurse is caring for a patient who is undergoing treatment for cancer. Which of the following symptoms would most likely indicate the need for palliative care?
Correct Answer: D
Rationale: The correct answer is D because palliative care aims to improve the quality of life for patients with serious illnesses like cancer. Severe pain and nausea (A) are common symptoms that palliative care helps manage. Uncontrolled symptoms despite treatment (B) indicate the need for specialized palliative care interventions. Psychosocial support needs (C) are also addressed in palliative care to address emotional and social aspects of the patient's well-being. Therefore, all of the above (D) are indicative of the need for palliative care as it focuses on holistic symptom management and support for the patient.