ATI RN
health assessment exam 2 test bank Questions
Question 1 of 9
What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?
Correct Answer: B
Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination. Incorrect Answers: A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention. C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion. D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.
Question 2 of 9
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
Question 3 of 9
A nurse is caring for a patient who has undergone a total knee replacement. Which of the following interventions is most important to prevent post-operative complications?
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.
Question 4 of 9
A nurse is teaching a patient with diabetes about managing foot care. Which of the following statements by the patient indicates proper understanding?
Correct Answer: A
Rationale: The correct answer is A: "I will inspect my feet daily for cuts or blisters." This statement indicates proper understanding because daily foot inspection is crucial for early detection of any wounds, which can prevent complications in diabetic patients. Incorrect choices: B: Avoiding trimming toenails can lead to ingrown nails and potential injury. C: Wearing tight shoes can increase the risk of blisters and discomfort. D: Ignoring small wounds can lead to infections and more serious foot issues. In summary, choice A is correct as it promotes proactive foot care, while the other choices can potentially harm the patient's foot health.
Question 5 of 9
A nurse is teaching a patient with diabetes about the importance of controlling blood glucose levels. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: The correct answer is B because stopping insulin when blood sugar is normal can lead to hyperglycemia. A: Monitoring blood sugar is essential for diabetes management. C: Eating balanced diet and exercising help control blood sugar levels. D: Avoiding sugary foods is important to manage blood sugar.
Question 6 of 9
A nurse is caring for a patient who is post-operative following a knee replacement. The nurse should monitor for signs of which of the following complications?
Correct Answer: C
Rationale: The correct answer is C: Deep vein thrombosis (DVT). After knee replacement surgery, the patient is at a higher risk for developing DVT due to immobility and altered blood flow. Monitoring for signs such as calf pain, swelling, and redness is crucial to prevent complications like pulmonary embolism. Pulmonary embolism (Choice A) is a potential complication of untreated DVT. Gastrointestinal bleeding (Choice B) is not directly related to knee replacement surgery. Hypoglycemia (Choice D) is not a common complication post-knee replacement. Monitoring for DVT is essential in preventing life-threatening complications for the patient.
Question 7 of 9
A nurse is caring for a patient with a history of stroke. The nurse should monitor the patient for signs of:
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.
Question 8 of 9
A nurse is providing discharge instructions to a patient with chronic hypertension. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C because stopping medication without consulting a healthcare provider can lead to uncontrolled hypertension. Choice A shows understanding of monitoring blood pressure, B demonstrates adherence to medication regimen, and D indicates awareness of dietary management. Choice C is incorrect because abruptly stopping medication can have serious health consequences, making further education necessary.
Question 9 of 9
During an interview, a woman says, "I just know labour will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labour." The nurse responds by stating, "Oh, don't worry about labour so much. I have been through it myself, and yes, it is painful, but there are many good medications to decrease the pain." Which of the following statements about this response is true?
Correct Answer: B
Rationale: The correct answer is B: It was a nontherapeutic response. The nurse responded in a way that downplayed the patient's concerns and shut down the conversation. Rationale: 1. The nurse's response of dismissing the woman's fear and immediately shifting the focus to medication options invalidates the woman's feelings. 2. By sharing her own experience without acknowledging the woman's emotions, the nurse fails to provide genuine support. 3. The response lacks empathy and fails to address the woman's emotional needs, thus hindering effective communication. 4. This type of response may discourage the woman from expressing her concerns openly in the future, leading to potential emotional distress. Summary of other choices: A: Incorrect. Sharing personal experience alone does not make it therapeutic. In this context, it did not address the woman's emotional concerns effectively. C: Incorrect. Providing information about medications, although helpful, does not address the woman's emotional distress and fears. D: Incorrect. While the response did minimize the patient