ATI RN
health assessment exam 1 test bank Questions
Question 1 of 9
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
Question 2 of 9
A nurse is assessing a 45-year-old male patient with a history of smoking. The nurse would be most concerned if the patient reports:
Correct Answer: A
Rationale: The correct answer is A because shortness of breath with minimal exertion indicates possible respiratory distress, which can be a sign of significant lung damage from smoking. This symptom suggests a decreased ability to exchange oxygen and carbon dioxide efficiently, potentially leading to serious health complications. Choice B is incorrect because an occasional cough with mucus production is common in smokers and may not be as alarming as shortness of breath. Choice C is incorrect as slight wheezing after physical activity could be due to exercise-induced asthma rather than solely smoking-related issues. Choice D is incorrect because even though the patient may not be experiencing symptoms related to smoking currently, it does not rule out potential underlying lung damage or future health risks associated with smoking.
Question 3 of 9
A nurse is providing discharge instructions to a patient who had a stroke. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.
Question 4 of 9
A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.
Question 5 of 9
A nurse is teaching a patient with asthma about managing triggers. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C: "I should smoke to relieve stress and manage symptoms." This statement indicates a need for further education because smoking can worsen asthma symptoms. Here's the rationale: 1. Smoking is a common trigger for asthma exacerbations due to irritants in tobacco smoke. 2. Smoking can lead to airway inflammation and constriction, making asthma symptoms more severe. 3. Asthma management involves avoiding smoking and secondhand smoke exposure. 4. Choices A, B, and D are correct as they align with asthma management guidelines to avoid triggers and use inhalers as prescribed.
Question 6 of 9
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for signs of which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease. B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely. C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication. D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.
Question 7 of 9
A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?
Correct Answer: B
Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.
Question 8 of 9
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over her other clothes. Her hair is dyed pink with black streaks. She has several piercings in her nares and ears and is wearing an earring on her eyebrow and heavy black makeup. The nurse concludes that:
Correct Answer: D
Rationale: The correct answer is D because more information should be gathered to assess the situation appropriately. The woman's appearance may suggest alternative lifestyles or personal expression rather than mental health issues. It is essential to avoid assumptions based solely on appearance and gather a comprehensive history to understand her choices. Options A and B are dismissive and judgmental, failing to consider the complexity of human behavior. Option C is incorrect as the presented information does not provide enough evidence to diagnose manic syndrome. In summary, option D is the most logical and ethical approach to understanding the woman's situation without making unfounded assumptions.
Question 9 of 9
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should monitor for which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.