ATI RN
advanced health assessment test bank Questions
Question 1 of 9
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
Correct Answer: A
Rationale: The correct answer is A because when a patient is experiencing significant shortness of breath, the nurse should initially focus on assessing the areas directly related to the presenting problem to address the immediate issue. This approach allows for prompt intervention and treatment of the patient's acute condition. Once the patient's respiratory distress is managed, the nurse can then proceed with a complete assessment to identify any underlying or additional health issues. This stepwise approach ensures that the patient's urgent needs are met first before conducting a comprehensive assessment. Choices B, C, and D are incorrect because: B: Performing a mini-database by only examining body areas directly related to the problem may not provide a comprehensive understanding of the patient's condition and could overlook other potential health issues. C: Dismissing significant shortness of breath as a normal finding and proceeding with an abdominal assessment is inappropriate and could delay necessary interventions for the respiratory distress. D: Examining the entire body to determine if the problem is linked to something else is inefficient and
Question 2 of 9
A man has come in to the clinic because he is afraid he might have skin cancer. During the skin assessment, the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on' on his skin. Which of the following is the best prediction?
Correct Answer: D
Rationale: The correct answer is D: He probably has seborrheic keratosis, which do not become cancerous. Seborrheic keratosis typically appear as greasy, dark, and "stuck on" pigmented growths on the skin, commonly seen in older adults. They are benign and do not progress to skin cancer. This conclusion is based on the characteristics of seborrheic keratosis and the fact that they are not associated with malignancy. Choice A (senile lentigines) is incorrect because although they are also common in older adults, they are flat and dark spots rather than raised growths. Choice B (actinic keratoses) is incorrect as they are precancerous lesions related to sun exposure, leading to a risk of developing squamous cell carcinoma, not basal cell carcinoma. Choice C (acrochordons) are skin tags and not precursors to squamous cell carcinoma.
Question 3 of 9
A nurse is caring for a patient with diabetes. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. In diabetes, hyperglycemia occurs when blood sugar levels are too high. This can lead to various complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. Monitoring for hyperglycemia is crucial to prevent these serious complications. A: Hypoglycemia is low blood sugar and can also occur in diabetes, but it is not the primary complication to monitor for in this case. B: Hyperkalemia is high potassium levels and is not a common complication of diabetes unless there are other underlying issues. C: Hypotension is low blood pressure, which can be a complication of diabetes but is not as directly related to glucose management as hyperglycemia. In summary, monitoring for hyperglycemia is essential in diabetes care to prevent serious complications associated with high blood sugar levels.
Question 4 of 9
A nurse is caring for a patient with diabetes who is experiencing diabetic neuropathy. The nurse should prioritize which of the following interventions?
Correct Answer: A
Rationale: The correct answer is A: Encouraging regular foot inspections. This is the priority intervention because diabetic neuropathy can lead to decreased sensation in the feet, increasing the risk of injury or infection. Regular foot inspections can help detect any issues early and prevent complications. Incorrect choices: B: Providing additional protein to the diet - While nutrition is important for overall health, providing additional protein does not directly address the specific issue of diabetic neuropathy. C: Encouraging weight loss to reduce joint stress - Weight loss may be beneficial for overall health, but it is not the priority intervention for diabetic neuropathy. D: Administering pain medication for relief - Pain management is important, but addressing the root cause through regular foot inspections is more essential in preventing further complications.
Question 5 of 9
A nurse is teaching a patient with diabetes about foot care. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A because daily inspection helps identify issues early, preventing complications. B is incorrect as tight shoes can cause blisters. C is wrong as proper toenail trimming is essential. D is incorrect because prevention is key in diabetic foot care.
Question 6 of 9
A nurse is teaching a patient with diabetes about insulin administration. Which of the following actions should the nurse emphasize to the patient?
Correct Answer: D
Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications. A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration. B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations. C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.
Question 7 of 9
Which of the following statements represents subjective data about the patient's skin?
Correct Answer: C
Rationale: The correct answer is C because it indicates that the information was provided directly by the patient and is based on their perception or feeling. Subjective data is based on the patient's experiences and cannot be observed or measured by others. Choices A, B, and D are all objective data as they can be observed or measured by healthcare providers. Choice A describes a visible characteristic of the skin, choice B indicates absence of observable lesions, and choice D reports an observed lesion on a specific location of the skin. Therefore, choice C is the only option that reflects subjective data about the patient's skin.
Question 8 of 9
A nurse is caring for a patient with acute pancreatitis. The nurse should monitor for which of the following signs of complications?
Correct Answer: C
Rationale: The correct answer is C: Hypotension and tachycardia. In acute pancreatitis, complications like hypovolemic shock can lead to hypotension and tachycardia due to fluid shifts and inflammation. Decreased urine output and increased thirst (A) may indicate dehydration but are not specific to pancreatitis. Increased blood pressure and heart rate (B) are not typical signs of complications in pancreatitis. Tachypnea and cyanosis (D) suggest respiratory distress, which is not a common complication of pancreatitis.
Question 9 of 9
The inspection phase of the physical assessment:
Correct Answer: B
Rationale: The correct answer is B because the inspection phase of a physical assessment involves visually examining the patient's body, which can reveal a surprising amount of information. This step is crucial in identifying visible abnormalities, such as skin discoloration, swelling, or asymmetry. It helps in assessing the patient's overall appearance, posture, and body movements. This detailed observation can provide valuable insights into the patient's health status and aid in making an accurate diagnosis. Choice A is incorrect because the inspection phase actually provides significant information. Choice C is incorrect as it downplays the importance of thorough observation. Choice D is incorrect because the discomfort level for the expert practitioner is not a defining factor in the inspection phase.