ATI RN
jarvis health assessment test bank pdf reddit Questions
Question 1 of 5
The nurse is preparing to examine an infant. Which of the following actions is the most appropriate to perform first?
Correct Answer: C
Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.
Question 2 of 5
When assessing older adults, the nurse knows that one of the first things that should be assessed before drawing conclusions about their mental health is:
Correct Answer: D
Rationale: The correct answer is D: Their sensory-perceptive abilities. Assessing sensory-perceptive abilities is crucial in older adults as sensory impairments can mimic signs of mental health issues. By assessing sensory functions first, the nurse can rule out any physical factors influencing the assessment. Phobias (A) and irrational thinking patterns (C) are psychological aspects that come after ruling out sensory issues. General intelligence (B) may not be the priority as cognitive decline can be affected by sensory impairments.
Question 3 of 5
Which of the following individuals would the nurse consider at highest risk for a suicide attempt?
Correct Answer: D
Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.
Question 4 of 5
Which of the following would illustrate an auditory hallucination?
Correct Answer: A
Rationale: The correct answer is A because an auditory hallucination involves hearing something that is not actually present. In this scenario, the man is hearing his dead wife talking to him, which is a perception without an external auditory stimulus. This illustrates an auditory hallucination. Choice B is incorrect as it describes a visual hallucination, seeing the doorbell indicator light up and hearing the bell ring. Choice C is also incorrect as it describes a visual misperception, seeing a man in the closet that turns out to be a dry cleaning bag. Choice D is incorrect as it describes a misinterpretation of a visual stimulus, mistaking a blanket for a dog.
Question 5 of 5
A score of 6 on the MoCA tool indicates:
Correct Answer: D
Rationale: A score of 6 on the MoCA tool indicates severe cognitive impairment because the MoCA is scored out of 30, with a lower score indicating more severe impairment. A score of 6 is significantly below the normal range, indicating severe cognitive deficits affecting various cognitive domains. This score would suggest significant impairment in memory, attention, language, visuospatial abilities, and executive functions. Therefore, Option D is correct. Options A, B, and C are incorrect as they suggest no, mild, or moderate impairment, which would not align with a score as low as 6 on the MoCA tool.