ATI RN
foundations of nursing test bank Questions
Question 1 of 9
The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify?
Correct Answer: D
Rationale: The correct answer is D: Improved coping with lifestyle modifications. This outcome is appropriate for a patient with allergic rhinitis as it focuses on helping the patient manage the condition through lifestyle changes, such as avoiding allergens and using medications as prescribed. By improving coping skills, the patient can better manage symptoms and reduce the impact of allergic rhinitis on daily life. Rationale: 1. A: Appropriate use of prophylactic antibiotics is not relevant for allergic rhinitis, which is not typically treated with antibiotics. 2. B: Safe injection of corticosteroids is not a primary treatment for allergic rhinitis and may not be necessary for all patients. 3. C: Improved skin integrity is not a priority outcome for allergic rhinitis, as it primarily affects the respiratory system, not the skin. Summary: Improving coping with lifestyle modifications is the most relevant outcome for a patient with allergic rhinitis, as it addresses the management of symptoms and overall quality of
Question 2 of 9
A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patients metastatic brain disease?
Correct Answer: D
Rationale: The correct answer is D: Personality changes. Metastases to the brain can affect cognitive function and behavior, leading to personality changes. This is due to the impact on specific areas of the brain responsible for personality and behavior. Chronic pain (A) is more commonly associated with advanced cancer and not specific to brain metastases. Respiratory distress (B) is more likely related to lung cancer itself, not brain metastases. Fixed pupils (C) may indicate brainstem involvement, but personality changes are a more direct and common manifestation of brain metastases.
Question 3 of 9
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth. Incorrect answers: A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy. B: A size of 5 mm - Tumor size alone does not determine malignancy. C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
Question 4 of 9
A laboratory finding indicatiNveU oRf SDIICN iGs oTnBe .thCatO sMhows
Correct Answer: A
Rationale: The correct answer is A: decreased fibrinogen. In disseminated intravascular coagulation (DIC), there is widespread activation of coagulation leading to consumption of clotting factors like fibrinogen, resulting in decreased levels. Platelets are usually decreased, not increased, in DIC. Hematocrit may be elevated due to hemoconcentration but not directly related to DIC. Thromboplastin time would be prolonged, not decreased, in DIC due to consumption of clotting factors.
Question 5 of 9
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
Correct Answer: D
Rationale: The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections. Explanation of why other choices are incorrect: A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse. B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections. C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.
Question 6 of 9
A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
Correct Answer: A
Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications. Summary of Incorrect Choices: B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial. C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms. D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.
Question 7 of 9
A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Diarrhea. In stage 3 HIV, gastrointestinal issues are common due to weakened immune system. Diarrhea can lead to dehydration and electrolyte imbalances, making it the priority nursing diagnosis. Acute Abdominal Pain (A) may be a symptom but not the priority. Bowel Incontinence (C) and Constipation (D) are less likely in stage 3 HIV.
Question 8 of 9
A patient with a genital herpes exacerbation has a nursing diagnosis of acute pain related to the genital lesions. What nursing intervention best addresses this diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Keep the lesions clean and dry. This intervention helps prevent infection and promotes healing. Cleaning the lesions reduces the risk of secondary infections and discomfort. Keeping the area dry can also help alleviate pain and discomfort associated with moisture. Covering with a topical antibiotic (A) may not address pain directly and could potentially irritate the lesions. Applying a topical NSAID (C) may provide some pain relief but does not address the primary need to keep the lesions clean and dry. Remaining on bed rest (D) is not necessary for managing acute pain related to genital lesions.
Question 9 of 9
An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?
Correct Answer: B
Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.