ATI RN
health assessment test bank jarvis Questions
Question 1 of 9
What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain. Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed. Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly. Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.
Question 2 of 9
Which factors increase the risk of sexually transmitted diseases (STDs)?
Correct Answer: D
Rationale: The correct answer is D: all of the above. Alcohol use can impair judgment leading to risky sexual behaviors. Certain sexual practices like unprotected sex or having multiple partners increase STD risk. Oral contraception does not protect against STDs. Therefore, all factors (A, B, C) collectively increase the risk of STDs.
Question 3 of 9
A nurse is teaching a patient with diabetes about managing diabetic neuropathy. Which of the following statements by the patient indicates the need for further education?
Correct Answer: B
Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.
Question 4 of 9
What is the most important nursing intervention for a client with pneumonia?
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating pneumonia caused by bacteria. They help to kill the bacteria causing the infection and prevent its spread. Administering fluids (B) is important for hydration but not the most crucial intervention. Monitoring temperature (C) is important but does not treat the root cause. Administering vaccines (D) may prevent certain types of pneumonia but is not the immediate intervention for an existing infection. Administering antibiotics promptly is vital to effectively treat pneumonia and prevent complications.
Question 5 of 9
Which of the following is the most appropriate response for a nurse caring for a client who is experiencing a stroke?
Correct Answer: B
Rationale: The correct answer is B: Initiate a stroke protocol. This is the most appropriate response because time is critical in treating a stroke. By initiating a stroke protocol, the nurse ensures that the client receives prompt and appropriate care, including timely evaluation, imaging studies, and potential interventions such as administering clot-busting medication. Performing a neurological assessment (A) is important but may delay crucial interventions. Positioning the client on their side (C) is essential for airway protection but should not be the initial priority. Starting a CT scan (D) is important for diagnosis but should not delay the initiation of the stroke protocol, which includes obtaining imaging studies.
Question 6 of 9
What is the first action the nurse should take when a client develops a deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected leg. This is the first action because elevating the leg helps reduce swelling and improve blood flow, reducing the risk of complications from the DVT. It also helps alleviate pain. Choice B: Applying compression stockings can be helpful in preventing DVT, but it is not the first action to take once it has developed. Choice C: Providing leg elevation is similar to choice A, but it lacks the specificity of elevating the affected leg to address the DVT directly. Choice D: Administering compression therapy may be necessary, but it is not the initial action to take when a client develops a DVT.
Question 7 of 9
A man has been admitted to the observation unit after having been treated for a large cut on his foreheaAs the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, "I quit smoking after my wife died 7 years ago." However, the nurse notices an open packet of cigarettes in his shirt pocket. If using confrontation as a response, the nurse could say:
Correct Answer: D
Rationale: The correct answer is D because using confrontation in this situation involves addressing the discrepancy between the patient's statement and observed behavior without being aggressive or judgmental. By stating, "Mr. K., I know that you are lying," the nurse directly addresses the inconsistency, encouraging honesty and open communication. This approach can help build trust and facilitate a more honest discussion about the patient's tobacco use. Choice A is incorrect as it is too direct and may come across as accusatory. Choice B is also incorrect as it does not acknowledge the discrepancy and may not lead to a productive conversation. Choice C is incorrect as it avoids addressing the issue and focuses on the patient's personal situation instead of the behavior in question.
Question 8 of 9
What is the primary concern for a nurse caring for a client who is post-operative and experiencing confusion?
Correct Answer: B
Rationale: The correct answer is B: Reorient the client. Reorientation helps the confused client regain awareness of their surroundings, time, and situation post-operatively. It can improve their cognition and reduce anxiety. Notifying the healthcare provider (A) may be necessary but not the primary concern. Increasing circulation (C) is important but not the first step for a confused post-op client. Assessing pain (D) is important but addressing confusion takes precedence.
Question 9 of 9
Which lab result is most indicative of infection in a client with a fever?
Correct Answer: A
Rationale: The correct answer is A: Increased white blood cell count. When a client has an infection, the body's immune response triggers an increase in white blood cells to help fight off the infection. Neutrophils and band cells (choice B) may also increase during infection, but a general increase in white blood cells is a more reliable indicator. ESR (choice C) is a nonspecific marker of inflammation and may be elevated in various conditions, not just infection. LDH (choice D) is an enzyme found in many tissues and can be elevated in various conditions, not specifically infection. Therefore, an increased white blood cell count is the most indicative of infection in a client with a fever.