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 nurse is caring for a patient with a history of chronic liver disease. The nurse should monitor for which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.
Question 3 of 9
The nurse is conducting an interview with a woman who has recently learned that she is pregnant and has come to the clinic to begin prenatal care. The woman states that she and her husband are excited about the pregnancy but have a few questions. She looks nervously at her hands during the interview and sighs audibly. Which of the following statements does the nurse know is most accurate, considering the concept of communication?
Correct Answer: B
Rationale: The correct answer is B because the woman's nonverbal cues (looking nervously at her hands, sighing audibly) indicate potential anxiety or stress. The nurse should acknowledge these cues and explore her feelings further to provide appropriate support. Option A is incorrect as it does not address the woman's nonverbal cues. Option C is incorrect as it assumes the woman is not genuinely excited about the pregnancy. Option D is incorrect as it overlooks the woman's nonverbal cues and does not address her potential emotional needs.
Question 4 of 9
The nurse is obtaining the health history of an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
Correct Answer: D
Rationale: Rationale: 1. Current health promotion activities are important to assess the patient's preventive measures. 2. At 87 years old, focusing on current habits can help identify areas for improvement. 3. Obstetrical history is irrelevant as the patient is postmenopausal. 4. Childhood illnesses are less relevant compared to current health status. 5. General health for the past 20 years may not reflect current health behaviors.
Question 5 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 6 of 9
A nurse is frequently bothered when a patient does not take the medications as prescribed until the patient speaks with her family. The nurse is so irritated by this behaviour that he often finds it hard to provide appropriate care to this individual. What should the nurse do first in trying to overcome his difficulty?
Correct Answer: B
Rationale: Step 1: Recognize Cultural Sensitivity - Understanding that family inclusion is a cultural practice is crucial as it helps the nurse appreciate the patient's perspective. Step 2: Empathy - Acknowledging the significance of family involvement for the patient shows empathy and respect for their beliefs and values. Step 3: Effective Communication - By recognizing and respecting the cultural practice, the nurse can build a trusting relationship with the patient and her family, leading to better adherence to medication and improved care outcomes. In summary, Option B is correct as it emphasizes cultural competence and patient-centered care. Options A, C, and D are incorrect as they do not address the core issue of cultural understanding and may hinder effective communication and relationship-building with the patient and her family.
Question 7 of 9
Which of the following are considered second-level priority problems?
Correct Answer: C
Rationale: The correct answer is C: Abnormal laboratory values. Second-level priority problems are those that are important to the patient's health but may not be life-threatening. Abnormal laboratory values fall into this category as they indicate an underlying health issue that needs attention. Low self-esteem (A) and lack of knowledge (B) are typically considered third-level priority problems, as they do not pose an immediate threat to the patient's health. Severely abnormal vital signs (D) are first-level priority problems, as they indicate an acute and potentially life-threatening situation that requires immediate intervention. Therefore, the correct answer is C as it aligns with the definition of second-level priority problems.
Question 8 of 9
A nurse is caring for a patient with pneumonia. The nurse should prioritize which of the following assessments?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation levels. This assessment is crucial in pneumonia to ensure adequate oxygenation. Low oxygen levels can lead to respiratory distress. Pain levels (B) are important but not a priority over oxygenation. Bowel sounds (C) are not directly related to pneumonia. Level of consciousness (D) is also important but not as critical as ensuring proper oxygen levels for a patient with pneumonia. Oxygen saturation levels should be prioritized to prevent complications and ensure the patient's respiratory status is stable.
Question 9 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.