ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease?
Correct Answer: B
Rationale: The correct answer is B: Facial paralysis. Bell's palsy is characterized by sudden, temporary weakness or paralysis of the facial muscles on one side of the face. This manifests as drooping of the eyelid and corner of the mouth, difficulty smiling or closing the eye. Tinnitus (A) is ringing in the ears, not a common symptom of Bell's palsy. Pain at the base of the tongue (C) is not a typical manifestation of Bell's palsy. Diplopia (D) is double vision, which is not a primary symptom of Bell's palsy. Therefore, the correct manifestation to address in the plan of care for a patient with Bell's palsy is facial paralysis.
Question 2 of 5
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?
Correct Answer: C
Rationale: The correct answer is C: Encourage the patient to keep his or her feeding area clean. This is the most appropriate independent nursing action as it promotes hygiene and reduces the risk of infection. Keeping the feeding area clean is essential in preventing complications in a patient with malnutrition. Rationales for why the other choices are incorrect: A: Firmly redirect the patient's head when feeding - This is incorrect because forceful redirection can cause distress and discomfort to the patient, potentially leading to aspiration or choking. B: Administer phenothiazines after each meal as ordered - This is incorrect as phenothiazines are not typically used for malnutrition treatment and should not be administered without a specific indication. D: Apply deep, gentle pressure around the patient's mouth to aid swallowing - This is incorrect because applying pressure around the mouth can pose a choking hazard and should not be done without proper assessment and intervention by a speech therapist or swallowing specialist.
Question 3 of 5
A patient has just returned to the unit from the PACU after surgery for a tumor within the spine. The patient complains of pain. When positioning the patient for comfort and to reduce injury to the surgical site, the nurse will position to patient in what position?
Correct Answer: B
Rationale: The correct answer is B: In a flat side-lying position. Rationale: 1. A flat side-lying position helps reduce pressure on the surgical site, promoting comfort and preventing injury. 2. This position minimizes strain on the spine and supports proper alignment. 3. High Fowlers position may increase pressure on the surgical area due to increased intra-abdominal pressure. 4. Trendelenberg position and reverse Trendelenberg position are not appropriate for spine surgery patients as they can cause increased blood flow to the surgical site, leading to potential complications.
Question 4 of 5
A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patients vomiting is most consistent with a brain tumor?
Correct Answer: C
Rationale: The correct answer is C: The patient's vomiting is unrelated to food intake. In the context of a brain tumor, vomiting that is not related to food intake can indicate increased intracranial pressure affecting the brain's vomiting center. This is known as projectile vomiting. A: Vomiting accompanied by epistaxis (nosebleeds) is more indicative of other conditions like hypertension or nasal issues, not necessarily specific to a brain tumor. B: Vomiting not relieving nausea can be seen in various conditions affecting the gastrointestinal system, not specifically brain tumors. D: Blood-tinged emesis can suggest gastrointestinal bleeding or other issues, but it's not a specific characteristic of vomiting associated with brain tumors.
Question 5 of 5
An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinsons disease. Which of the wifes descriptions of her husbands health and function is most suggestive of Parkinsons disease?
Correct Answer: A
Rationale: The correct answer is A because one of the hallmark symptoms of Parkinson's disease is bradykinesia, which is characterized by slowness of movement. This symptom commonly presents as a person moving far more slowly than usual. Option B is more indicative of arthritis or another musculoskeletal condition. Option C suggests possible cognitive decline or dementia, not specific to Parkinson's disease. Option D could indicate a different medical condition causing weight loss despite a good appetite. Therefore, A is the most suggestive of Parkinson's disease based on the symptom of bradykinesia.