ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that do not apply.)
Correct Answer: A
Rationale: Step-by-step rationale: 1. Chest x-ray is not routinely scheduled annually for monitoring complications in type 2 diabetes. 2. Blood pressure monitoring is essential for assessing cardiovascular risk in diabetic patients. 3. Serum creatinine levels are checked annually to assess kidney function. 4. Urine for microalbuminuria is done annually to detect early signs of kidney damage. 5. Since chest x-ray is not directly related to diabetes complications, it is the correct answer. Summary: A is correct because chest x-ray is not a standard test for monitoring type 2 diabetes complications. B, C, and D are incorrect as they are essential for evaluating cardiovascular risk, kidney function, and early signs of kidney damage in diabetic patients.
Question 2 of 5
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Perform a test focused on a neurologic examination. The client's symptoms indicate potential neurological issues, such as vision difficulties and constant nasal drainage, which could be related to nerve damage from the nasal fracture. By performing a neurologic examination, the nurse can assess for any nerve involvement and determine the extent of the injury. This action is crucial in identifying any neurological complications and guiding appropriate treatment. Summary: A: Collecting nasal drainage does not address the client's neurological symptoms. B: Encouraging the client to blow his or her nose could exacerbate the nasal fracture and is not relevant to the neurological symptoms. D: Palpating the nose, face, and neck may help assess the extent of the fracture but does not address the neurological symptoms reported by the client.
Question 3 of 5
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Puffy face and swollen eyelids can indicate a potential airway obstruction, which is a medical emergency. Notifying the Rapid Response Team ensures prompt intervention and appropriate management. Assessing oxygen saturation (A) may be important but addressing the potential obstruction takes priority. Oxygenating with a bag-valve-mask (C) may worsen the obstruction. Palpating the skin of the upper chest (D) is not directly related to addressing the potential airway issue.
Question 4 of 5
A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud's phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient?
Correct Answer: C
Rationale: The correct answer is C: Autoimmune disorders. Raynaud's phenomenon is often associated with autoimmune conditions, such as systemic lupus erythematosus or scleroderma. Testing for autoimmune disorders may involve blood tests to check for specific antibodies or inflammatory markers. Hyperglycemia (A) is high blood sugar levels, not directly related to Raynaud's. Hyperlipidemia (B) is high levels of fats in the blood, not typically associated with Raynaud's. Coronary artery disease (D) involves the narrowing of the arteries that supply blood to the heart, which is not directly related to Raynaud's phenomenon.
Question 5 of 5
The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain is from an acute myocardial infarction?
Correct Answer: B
Rationale: The correct answer is B because chest pain lasting longer than 30 minutes is a common characteristic of an acute myocardial infarction (heart attack). This prolonged duration indicates cardiac tissue damage. Choices A, C, and D are incorrect. Choice A, pain increasing with deep breathing, is more indicative of musculoskeletal pain. Choice C, pain relieved by nitroglycerin, is suggestive of angina rather than a heart attack. Choice D, reproducible pain with arm movement, is more consistent with musculoskeletal or nerve-related pain rather than a heart attack.