ATI RN
foundations of nursing test bank Questions
Question 1 of 5
The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
Correct Answer: A
Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.
Question 2 of 5
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Diabetic retinopathy. This is because diabetic retinopathy is a leading cause of blindness in adults over 40, resulting from diabetes affecting blood vessels in the retina. Trauma (B) is a common cause of visual impairment but not as prevalent as diabetic retinopathy in this age group. Macular degeneration (C) primarily affects older individuals, typically over 50, rather than those over 40. Cytomegalovirus (D) is a cause of blindness in immunocompromised individuals, not specific to the age group mentioned. Glaucoma (E) is a leading cause of blindness worldwide but is more common in older adults and not specifically over 40.
Question 3 of 5
A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?
Correct Answer: C
Rationale: The correct answer is C: Assessing and addressing the patient's emotional needs. This should be prioritized because the patient has undergone a traumatic experience losing their eye due to a workplace accident. Emotions such as fear, anxiety, and grief are common postoperatively. Addressing these emotional needs is crucial for the patient's overall well-being and recovery. Options A, B, and D are important aspects of care but not the priority in this situation. Teaching about eye prostheses, depth perception, and medication regimen can be addressed once the patient's emotional needs are stabilized.
Question 4 of 5
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care. B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site. C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider. D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation. E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more
Question 5 of 5
Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.