ATI RN
foundations of nursing practice questions Questions
Question 1 of 5
The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?
Correct Answer: C
Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.
Question 2 of 5
A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Hearing-impaired patient is likely unable to hear during an MRI due to loud noises. 2. Nurse needs to use alternative communication methods like writing or gestures. 3. Sign language interpreter may not be necessary for an MRI. 4. Lip reading may be challenging due to the noisy MRI environment. 5. Interaction should be adapted to accommodate the patient's communication needs.
Question 3 of 5
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.
Question 4 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 5 of 5
A patient with suspected Parkinsons disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?
Correct Answer: A
Rationale: The correct answer is A: When the patient is resting. This is because the tremor associated with Parkinson's disease is most noticeable when the patient is at rest due to the characteristic "resting tremor" seen in this condition. The tremor tends to lessen or disappear with purposeful movements or activities, making it more difficult to assess during ambulation, meal preparation, or occupational therapy. By observing the patient at rest, the nurse can accurately assess the presence and severity of the tremor, which is a key diagnostic feature of Parkinson's disease. Other answer choices are incorrect because they do not provide the optimal condition for assessing the tremor associated with Parkinson's disease.