ATI RN
foundations of nursing practice questions Questions
Question 1 of 9
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 9
The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely
Question 3 of 9
The nurse is caring for a patient has just been given a 6-month prognosis following a diagnosis of extensive stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the patients care needs are unable to be met in a home environment. What might you suggest as an alternative?
Correct Answer: D
Rationale: The correct answer is D: Discuss a referral for hospice care. Hospice care provides specialized care for patients with terminal illnesses, focusing on comfort and quality of life. This option aligns with the patient's wish to die at home and ensures his care needs are met. Hospice care also provides emotional and spiritual support for both the patient and family. A: Discuss a referral for rehabilitation hospital - This option focuses on rehabilitation, which is not suitable for a patient with a terminal illness like extensive stage small-cell lung cancer. B: Panel the patient for a personal care home - Personal care homes may not provide the level of specialized care needed for a terminally ill patient. C: Discuss a referral for acute care - Acute care is more focused on treating acute illnesses and injuries, not providing end-of-life care for a patient with a terminal illness.
Question 4 of 9
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 9
A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking?
Correct Answer: A
Rationale: Step 1: The nurse is auditing and monitoring patients' health records, indicating a review process. Step 2: By reviewing patients' health records, the nurse is determining the degree to which standards of care are met. Step 3: This action aligns with auditing, which involves assessing if care meets established standards. Step 4: The other choices are incorrect because they do not directly involve auditing or monitoring for compliance with standards of care. Choice B talks about undocumented care, C about reimbursement, and D about treatment outcomes comparison.
Question 6 of 9
You are caring for a 50-year-old man diagnosed with multiple myeloma; he has just been told by the care team that his prognosis is poor. He is tearful and trying to express his feelings, but he is having difficulty. What should you do first?
Correct Answer: A
Rationale: The correct answer is A: Ask if he would like you to sit with him while he collects his thoughts. Rationale: 1. Active listening: By offering to sit with him, you show empathy and support his emotional expression. 2. Respect his autonomy: Asking if he would like you to sit allows him to make a choice about what support he needs. 3. Nonjudgmental approach: Sitting with him creates a safe space for him to share his feelings without feeling rushed or judged. Summary: B: Leaving abruptly may make him feel abandoned in a vulnerable moment. C: While spiritual support can be beneficial, it may not address his immediate emotional needs. D: Reassurance is important but may not be as effective as actively listening and offering support in this context.
Question 7 of 9
A patient with a family history of allergies has suffered an allergic response based on a genetic predisposition. This atopic response is usually mediated by what immunoglobulin?
Correct Answer: D
Rationale: The correct answer is D: Immunoglobulin E. The atopic response in allergies is mainly mediated by IgE antibodies. IgE binds to allergens and triggers the release of histamine and other chemicals that cause allergic symptoms. IgA is mainly found in mucosal areas, IgM is involved in early immune responses, and IgG is important for long-term immunity. IgE is specifically associated with allergic reactions due to its role in sensitizing mast cells and basophils to allergens.
Question 8 of 9
A patient is experiencing oliguria. Which actionshould the nurse performfirst?
Correct Answer: A
Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.
Question 9 of 9
After contributing to the care of several patients who died in the hospital, the nurse has identified some lapses in the care that many of these patients received toward the end of their lives. What have research studies identified as a potential deficiency in the care of the dying in hospital settings?
Correct Answer: A
Rationale: The correct answer is A. Research studies have consistently shown that families' needs for information and support often go unmet in hospital settings when caring for dying patients. This is a crucial deficiency as effective communication and support for families can greatly impact the quality of care provided to the dying patient. When families are not adequately informed and supported, it can lead to increased stress, confusion, and dissatisfaction with the care provided. Choices B, C, and D are incorrect because they do not address the specific deficiency identified in research studies. While pain control, communication, and attention from caregivers are important aspects of end-of-life care, the primary focus in this scenario is on the unmet needs of families for information and support. Ignoring families' needs can have significant negative consequences on the overall care provided to the dying patient.