ATI RN
test bank foundations of nursing Questions
Question 1 of 9
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.
Question 2 of 9
The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Correct Answer: C
Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.
Question 3 of 9
The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patients health education?
Correct Answer: C
Rationale: The correct answer is C: The need to perform thorough hand hygiene before handling the prosthesis. This is crucial to prevent infection. By washing hands thoroughly, the patient reduces the risk of introducing harmful bacteria or pathogens to the prosthesis, which could lead to infections or other complications. Incorrect Choices: A: The need to limit exposure to bright light - This is not directly related to caring for an ocular prosthesis. B: The need to maintain a low Fowlers position when removing the prosthesis - Positioning is not typically a concern when caring for an ocular prosthesis. D: The need to apply antiviral ointment to the prosthesis daily - Antiviral ointment is not a standard part of ocular prosthesis care unless specifically prescribed by a healthcare provider for a particular reason.
Question 4 of 9
A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
Correct Answer: C
Rationale: The correct answer is C: Protecting the safety of the patient, family, and staff. This is the priority when planning care for a patient undergoing radiation therapy due to the potential risks of radiation exposure to others. Ensuring safety involves implementing proper radiation safety protocols, educating the patient and family on safety measures, and providing a safe environment for all. Choices A, B, and D are incorrect. Preventing hemorrhage is important but not the top priority during radiation therapy. Ensuring the patient understands the treatment's purpose is essential but not the immediate priority. Adherence to dietary restrictions is important for overall health but is not the primary focus when prioritizing actions for radiation therapy.
Question 5 of 9
An oncology nurse educator is providing health education to a patient who has been diagnosed with skin cancer. The patients wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite?
Correct Answer: B
Rationale: The correct answer is B: Malignant cells contain proteins called tumor-specific antigens. Tumor-specific antigens are unique to cancer cells and are not found in normal cells. This characteristic distinguishes cancer cells from normal cells and is important in cancer detection and treatment. A: Malignant cells do not necessarily contain more fibronectin than normal body cells. Fibronectin is a glycoprotein found in the extracellular matrix and is not a defining characteristic of cancer cells. C: Chromosomes in cancer cells are actually more prone to instability and mutations compared to normal cells, making them less durable and stable. D: The nuclei of cancer cells can vary in size and shape, with irregularities often seen, rather than being unusually large and regularly shaped.
Question 6 of 9
A patient has presented for her annual mammogram. The patient voices concerns related to exposure to radiation. What should the nurse teach the patient about a mammogram?
Correct Answer: A
Rationale: Step 1: Mammograms use low-dose X-rays to create images of the breast tissue. Step 2: The radiation exposure in a mammogram is minimal and considered safe. Step 3: Choice A is correct as it states that mammograms do not use radiation, which is accurate. Step 4: Other choices are incorrect because B wrongly implies that annual mammograms are safe due to low radiation levels, C is incorrect as radiation effects can accumulate over time, and D is incorrect as the amount of radiation in a mammogram is much lower than an hour of sunlight.
Question 7 of 9
An adolescent patients history of skin hyperreactivity and inflammation has been attributed to atopic dermatitis. The nurse should recognize that this patient consequently faces an increased risk of what health problem?
Correct Answer: D
Rationale: The correct answer is D: Asthma. Atopic dermatitis is associated with a heightened immune response and inflammation, which can predispose individuals to developing asthma. Both conditions involve an overactive immune response and can coexist in patients due to shared genetic and environmental factors. Asthma commonly presents alongside atopic dermatitis in individuals with atopic tendencies. Bronchitis (choice A) is a respiratory condition caused by inflammation of the bronchial tubes and is not directly linked to atopic dermatitis. Systemic lupus erythematosus (choice B) and rheumatoid arthritis (choice C) are autoimmune diseases that primarily affect the joints and other organs, but they are not typically associated with atopic dermatitis.
Question 8 of 9
A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?
Correct Answer: C
Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.
Question 9 of 9
A woman is considering breast reduction mammoplasty. When weighing the potential risks and benefits of this surgical procedure, the nurse should confirm that the patient is aware of what potential consequence?
Correct Answer: D
Rationale: The correct answer is D: Decreased nipple sensation. During breast reduction mammoplasty, nerves responsible for nipple sensation may be disrupted, leading to decreased sensation in the nipple area. This is an important consequence to consider as it can impact the patient's satisfaction and quality of life post-surgery. Other choices are incorrect because: A: Chronic breast pain is a potential risk of surgery but not a consequence directly related to nipple sensation. B: Unclear mammography results may occur due to breast tissue changes from surgery, but it is not a direct consequence of decreased nipple sensation. C: Increased risk of breast cancer is not a common consequence of breast reduction mammoplasty and is not directly related to nipple sensation.