ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
The nurse is using a stethoscope to listen for bowel sounds. What should the nurse ensure before using the stethoscope?
Correct Answer: B
Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.
Question 2 of 5
A patient is admitted after an automobile accident. The nurse begins the mental health examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach in this situation is to:
Correct Answer: A
Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.
Question 3 of 5
The nurse has decided to administer the Set Test to Mr. C., age 70 years. To administer this test the nurse needs to:
Correct Answer: B
Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.
Question 4 of 5
An example of a cognition area for the mental health examination is:
Correct Answer: B
Rationale: The correct answer is B: Orientation, as it assesses a person's awareness of time, place, and person. This is crucial for evaluating cognitive functioning in mental health exams. Speech (A) is related to communication, Perception (C) involves interpreting sensory information, and Judgement (D) pertains to decision-making skills. However, in the context of a mental health examination, assessing orientation is essential for understanding a person's cognitive status and ability to interact with their environment effectively.
Question 5 of 5
A patient is experiencing tingling sensations in her feet and has also noticed that her tongue has become very red and painful. The nurse suspects that she has:
Correct Answer: B
Rationale: The correct answer is B: Pernicious anemia. This condition is characterized by a deficiency in vitamin B12, leading to neurological symptoms like tingling sensations in the feet (peripheral neuropathy) and glossitis, causing the tongue to become red and painful. Polycythemia (A) is an increase in red blood cell mass, not related to the symptoms described. Micronucleus anemia (C) is not a recognized medical condition. Iron-deficiency anemia (D) can lead to symptoms like fatigue and pallor, but not typically tingling sensations in the feet or glossitis.