ATI RN
health assessment test bank jarvis Questions
Question 1 of 9
What is the highest priority for a nurse treating a client with a stab wound to the chest?
Correct Answer: A
Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.
Question 2 of 9
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
Question 3 of 9
A patient is describing his symptoms to the nurse. Which of the following statements is a description of the setting of his symptoms?
Correct Answer: D
Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.
Question 4 of 9
A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to enjoy doing.' He also says that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, which of the following questions should the nurse ask him?
Correct Answer: C
Rationale: Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis. Summary of other choices: A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders. B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders. D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not
Question 5 of 9
When interviewing a patient, it is important for the nurse to obtain some basic history. Which of the following statements should be explored more fully during an interview? The patient states that he:
Correct Answer: C
Rationale: The correct answer is C: "Never did too good in school." This statement should be explored further during an interview because it can provide insights into the patient's educational background, potential learning difficulties, or past experiences that may impact their health literacy or understanding of medical information. Understanding the patient's educational history can help the nurse tailor communication and education strategies effectively. A: "Sleeps like a baby" is not as critical for further exploration as it pertains to the patient's sleep quality. B: "Has no health problems" is important information but does not require immediate further exploration. D: "Is currently not taking any medication" is important for medication reconciliation but does not warrant immediate further exploration in this context.
Question 6 of 9
The nurse is assessing a teenage girl newly admitted to the pediatric unit. What efficient framework provides additional modesty?
Correct Answer: D
Rationale: The correct answer is D: Head to toe. The head-to-toe assessment is efficient because it follows a systematic approach starting from the head and progressing downward, ensuring that all body parts are assessed while maintaining the patient's modesty. This approach allows the nurse to gather comprehensive data without compromising the patient's privacy. A: Body systems - While assessing by body systems is important, it may not provide the same level of modesty as the head-to-toe approach. B: Functional - Assessing by function focuses on specific body functions rather than a comprehensive assessment of all body systems. It may not address all aspects of the patient's health. C: Focused - A focused assessment targets specific health issues and may not cover all body systems comprehensively, potentially missing important findings.
Question 7 of 9
What is the highest priority for a nurse treating a client with a stab wound to the chest?
Correct Answer: A
Rationale: The correct answer is A: Secure the airway. This is the highest priority for a nurse treating a client with a stab wound to the chest because airway management is crucial for ensuring the client can breathe effectively. If the airway is compromised, the client may not be able to oxygenate properly, leading to serious complications or even death. Administering oxygen (choice B) can help with oxygenation but is not as critical as ensuring the airway is clear. Turning the client (choice C) or applying an abdominal binder (choice D) are not appropriate actions for a stab wound to the chest and would not address the immediate life-threatening issue of airway compromise.
Question 8 of 9
What is the most important intervention for a client with acute pancreatitis?
Correct Answer: D
Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.
Question 9 of 9
What is the most important nursing intervention for a client with severe dehydration?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. This is the most important nursing intervention for a client with severe dehydration because IV fluids provide rapid rehydration and help restore electrolyte balance efficiently. Monitoring vital signs (choice B) is important but not as crucial as providing immediate fluid replacement. Providing oral rehydration (choice C) may not be effective for severe dehydration as the client may have difficulty absorbing fluids orally. Administering oxygen (choice D) is not directly related to treating dehydration, so it is not the most important intervention in this scenario.