ATI RN
health assessment test bank Questions
Question 1 of 9
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
Correct Answer: B
Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.
Question 2 of 9
A woman is describing the problems she is having with her 2-year-old son. "He won't go to sleep at night, and during the day he has several fits. I get so upset when that happens." The nurse's best verbal response would be:
Correct Answer: B
Rationale: The correct answer is B because it demonstrates active listening and seeks clarification on the issue at hand. By asking the woman to explain what she means by "fits," the nurse can gain a better understanding of the child's behavior and provide appropriate support and guidance. This response shows empathy and a willingness to address the woman's concerns effectively. Choice A is incorrect because it does not address the woman's specific concerns or invite further discussion. Choice C is incorrect because it simply acknowledges the woman's feelings without delving deeper into the issue. Choice D is incorrect as it dismisses the woman's feelings and generalizes the behavior as typical for all 2-year-olds without addressing her individual situation.
Question 3 of 9
A nurse is caring for a patient with hypertension. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D. Hypertension can lead to various complications affecting the heart, kidneys, and brain. Monitoring for heart failure is crucial due to the increased workload on the heart. Chronic kidney disease is a common complication of hypertension, as the kidneys are sensitive to changes in blood pressure. Stroke is another significant risk due to the potential damage to blood vessels in the brain. Therefore, monitoring for all these complications is essential in managing a patient with hypertension. Other choices are incorrect as they do not encompass all possible complications of hypertension.
Question 4 of 9
Which client must avoid foods high in potassium?
Correct Answer: D
Rationale: The correct answer is D. A client with renal disease must avoid foods high in potassium to prevent hyperkalemia, as the kidneys are unable to properly filter and excrete potassium. Foods high in potassium can lead to dangerous levels of potassium in the blood, which can be life-threatening for individuals with renal disease. Choice A is incorrect because a client receiving diuretic therapy may actually need to increase their potassium intake due to the potassium-wasting effects of diuretics. Choice B is incorrect as having an ileostomy does not necessarily affect potassium levels. Choice C is incorrect because clients with metabolic alkalosis may actually benefit from consuming foods high in potassium to help correct the acid-base imbalance.
Question 5 of 9
A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function. A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism. B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism. D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.
Question 6 of 9
Which intervention should the nurse implement for a client who is experiencing a seizure?
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.
Question 7 of 9
The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?
Correct Answer: B
Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety. Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus. Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected. Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.
Question 8 of 9
What does a focused assessment primarily address?
Correct Answer: B
Rationale: The correct answer is B: Specific client issues. A focused assessment is a targeted examination that addresses specific client concerns or issues. By focusing on a particular aspect of the client's health, healthcare providers can gather relevant information efficiently and effectively. This approach allows for a more in-depth evaluation of the specific problem at hand, leading to better treatment outcomes. Choice A (Comprehensive physical findings) is incorrect because a focused assessment does not aim to gather information on all physical findings, but rather on specific issues. Choice C (Multiple body systems) is incorrect because a focused assessment is more narrow in scope and typically focuses on one area or system of the body. Choice D (Long-term wellness goals) is incorrect as a focused assessment is more immediate and targeted towards addressing current issues rather than long-term goals.
Question 9 of 9
What is the most important intervention for a client with a wound infection?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating wound infections as they target and eliminate the infection-causing bacteria, preventing the infection from spreading and promoting healing. Applying a cold compress (choice B) or heat (choice C) may provide temporary relief but do not address the underlying infection. Administering IV fluids (choice D) may be necessary for hydration, but it does not directly treat the infection. Antibiotics directly target the infection, making it the most important intervention for a client with a wound infection.