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 comes to the clinic complaining of severe itching on her lower legs. Upon examination, the nurse notices red, scaly patches on the skin. The nurse suspects that this is:
Correct Answer: A
Rationale: The correct answer is A: Psoriasis. Psoriasis is characterized by red, scaly patches on the skin, which align with the symptoms described. Psoriasis commonly affects the lower legs and is associated with severe itching. Eczema (choice B) is characterized by red, inflamed, and itchy skin patches, but typically presents differently from psoriasis. Contact dermatitis (choice C) is a localized reaction that occurs when the skin comes into contact with an irritant or allergen, and fungal infections (choice D) typically present with itching, redness, and sometimes peeling skin, but not necessarily scaly patches like psoriasis.
Question 3 of 9
A patient tells the nurse that he is very nervous, that he is nauseated, and that he "feels hot." This type of data would be:
Correct Answer: C
Rationale: The correct answer is C: subjective. Subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient's report of feeling nervous, nauseated, and hot is subjective because it reflects their personal sensations and cannot be measured or observed directly by the nurse. Objective data (choice A) is measurable and observable, such as vital signs or physical examination findings. Reflective (choice B) and introspective (choice D) do not accurately describe the type of data provided by the patient in this scenario. The patient's symptoms are subjective because they are based on the patient's own feelings and experiences, making choice C the most appropriate answer.
Question 4 of 9
A nurse is assessing a patient who is experiencing dizziness and weakness. The nurse should prioritize which of the following?
Correct Answer: A
Rationale: The correct answer is A: Blood pressure measurement. Dizziness and weakness can be symptoms of hypotension or low blood pressure. Prioritizing blood pressure measurement is crucial because it can indicate if the patient is at risk of complications like cardiovascular collapse. Pulse oximetry (B) is important for assessing oxygen levels in the blood but may not directly address dizziness and weakness. Blood glucose levels (C) are important but not the priority in this scenario. Cardiac monitoring (D) may be necessary but should come after assessing blood pressure to rule out immediate life-threatening conditions.
Question 5 of 9
Which client should avoid foods high in potassium?
Correct Answer: D
Rationale: The correct answer is D because clients with renal disease may have impaired kidney function, leading to difficulty in regulating potassium levels. High potassium intake can further burden the kidneys, potentially causing hyperkalemia. Clients on diuretic therapy (choice A) may actually need to monitor potassium levels due to potential electrolyte imbalances. Clients with an ileostomy (choice B) typically do not have issues with potassium absorption. Clients with metabolic alkalosis (choice C) may have potassium shifts but do not necessarily need to avoid high-potassium foods unless specifically advised by their healthcare provider.
Question 6 of 9
What is the most appropriate action for a client with a history of asthma who is experiencing wheezing?
Correct Answer: A
Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open the airways, relieving wheezing in asthma patients. It is the first-line treatment for acute asthma exacerbations. Antihistamines (B) do not treat asthma symptoms. Monitoring for infection (C) is important but not the immediate action for wheezing. Epinephrine (D) is used for severe allergic reactions, not routine asthma management.
Question 7 of 9
A 47-year-old woman who is a recent immigrant to Canada is being seen at the clinic today for her uncontrolled diabetes. The nurse knows that the patient lives with her husband and a large extended family. The nurse concludes that part of the patient's inability to maintain and comply with her diet and diabetic regime is the foods that this patient eats. This conclusion is an example of:
Correct Answer: D
Rationale: The correct answer is D: culturalism. The nurse's conclusion that the patient's inability to maintain her diet and diabetic regime is due to the foods she eats reflects culturalism. Culturalism refers to the belief that a person's behaviors and beliefs are solely determined by their culture. In this case, the nurse is attributing the patient's struggles solely to her cultural background without considering other factors. A: Cultural sensitivity is about being aware and respectful of different cultures, but it does not involve making assumptions based on culture alone. B: Cultural safety is about creating a safe and respectful environment for individuals from different cultures, but it does not involve making assumptions about behavior solely based on culture. C: Cultural perspective involves understanding different cultural viewpoints, but it does not involve making assumptions about behavior solely based on culture. In summary, the nurse's conclusion is an example of culturalism as it oversimplifies the patient's situation by attributing her struggles solely to her cultural background.
Question 8 of 9
A nurse is caring for a patient who is post-operative following an abdominal surgery. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation to prevent deep vein thrombosis. Early ambulation helps prevent blood clot formation in the legs, reducing the risk of deep vein thrombosis post-surgery. It also promotes circulation and aids in preventing complications like pneumonia. Administering pain medication (B) is important, but preventing complications should take priority. Providing wound care (C) is essential but not the top priority. Encouraging a high-protein diet (D) is beneficial for healing, but immediate post-operative mobility is crucial for preventing complications.
Question 9 of 9
Which is included only in a comprehensive assessment?
Correct Answer: C
Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.