ATI RN
Health Assessment Practice Questions Questions
Question 1 of 9
What is the most appropriate action for a nurse when caring for a client with severe hypothermia?
Correct Answer: A
Rationale: The correct answer is A: Administer warm IV fluids. This is because in severe hypothermia, the body's core temperature drops dangerously low, leading to decreased circulation and potential organ failure. Administering warm IV fluids helps to gradually raise the core temperature and prevent further complications. Choice B (Warming the client with a heating pad) can cause rewarming shock and skin burns. Choice C (Placing the client in a supine position) is not directly related to treating hypothermia. Choice D (Administering analgesics) is not the priority in treating severe hypothermia.
Question 2 of 9
What should the nurse do first for a client with a history of diabetes who is experiencing hypoglycemia?
Correct Answer: A
Rationale: The correct answer is A: Administer glucose. In hypoglycemia, the priority is to raise the low blood sugar levels quickly. Administering glucose is the most direct and effective way to do so. Glucose will rapidly increase the blood sugar levels and help the client recover from hypoglycemia. Administering insulin (B) would further lower blood sugar levels. Administering glucagon (C) is used for severe hypoglycemia when the client is unconscious. Encouraging deep breathing (D) is not effective in treating hypoglycemia and does not address the immediate need to raise blood sugar levels.
Question 3 of 9
A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding:
Correct Answer: C
Rationale: The correct answer is C because pain in the ear when people speak loudly can be a sign of a middle ear infection. This is due to increased pressure in the middle ear caused by inflammation or fluid buildup. Recruitment (B) is a phenomenon related to hearing loss, not ear pain. Cerumen impaction (D) would not typically cause pain in response to loud sounds. It is not normal for a person of that age to experience ear pain when people speak loudly (A).
Question 4 of 9
During an examination, the nurse finds that a patient's left temporal artery is more tortuous and feels hardened and tender compared with the right temporal artery. What condition does the nurse suspect?
Correct Answer: C
Rationale: The correct answer is C: Temporal arteritis. Temporal arteritis is characterized by inflammation of the temporal arteries, leading to symptoms such as tenderness, hardness, and tortuosity. The left temporal artery being more affected than the right is a common presentation. Crepitation (choice A) refers to a crackling sound or sensation, typically associated with bone or joint abnormalities, not arterial inflammation. Mastoiditis (choice B) is an infection of the mastoid bone behind the ear, not related to temporal arteries. Bell's palsy (choice D) is a condition affecting facial nerves, not arteries.
Question 5 of 9
A patient's vision is recorded as 20/80 in each eye. The nurse recognizes that this finding indicates:
Correct Answer: A
Rationale: The correct answer is A: poor vision. In the 20/80 visual acuity notation, 20 represents the test distance in feet, and 80 represents the line on the eye chart that the patient can read. Therefore, a person with 20/80 vision can only see at 20 feet what a person with normal vision can see at 80 feet. This indicates poor vision as the patient's visual acuity is significantly below normal. Summary: - Choice B (acute vision) is incorrect as 20/80 vision indicates poor vision, not exceptional sharpness. - Choice C (normal vision) is incorrect as 20/80 vision is below normal range. - Choice D (presbyopia) is incorrect as presbyopia is a condition related to aging and difficulty focusing on close objects, not specifically indicated by 20/80 vision.
Question 6 of 9
During the assessment of an infant, the nurse notes that the fontanelles are depressed and sunken. Which condition does the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Dehydration. Depressed and sunken fontanelles in an infant indicate dehydration due to decreased fluid volume. Dehydration causes a decrease in tissue turgor, leading to the fontanelles appearing sunken. Rickets (A) is a condition characterized by weak or soft bones due to vitamin D deficiency. Mental retardation (C) is a developmental disorder, not related to fontanelle appearance. Increased intracranial pressure (D) would cause bulging fontanelles, not depressed fontanelles. Therefore, the most likely condition in this case is dehydration.
Question 7 of 9
Which electrolyte is lost with intestinal suctioning in a client with an ileus?
Correct Answer: D
Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.
Question 8 of 9
What is the primary goal for a client with newly diagnosed diabetes?
Correct Answer: B
Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.
Question 9 of 9
What should be the first step in managing a client with suspected spinal cord injury?
Correct Answer: A
Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.