ATI RN
jarvis health assessment test bank Questions
Question 1 of 9
What is the most effective action when a client with a history of stroke develops difficulty speaking?
Correct Answer: B
Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.
Question 2 of 9
Which of the following is the most important goal for a nurse when implementing care for a patient with a chronic illness?
Correct Answer: C
Rationale: The most important goal for a nurse when implementing care for a patient with a chronic illness is to prevent future complications (Choice C). This is because chronic illnesses are long-term conditions that require ongoing management to minimize the risk of complications and improve the patient's quality of life. By preventing future complications, the nurse helps maintain the patient's health and prevents the progression of the disease. Providing emotional support (Choice D) is important but not the most crucial goal in this context. While reducing symptoms (Choice B) is important, preventing future complications takes precedence as it addresses the underlying cause of the illness. Curing the disease (Choice A) may not always be feasible for chronic illnesses, making prevention of complications a more realistic and essential goal.
Question 3 of 9
A patient is admitted after an automobile accident. The nurse begins the mental health examination and finds that the patient's speech is dysarthric and that she is lethargic. The nurse's best approach in this situation is to:
Correct Answer: A
Rationale: The correct approach is to defer the rest of the mental health examination. This is because the patient's symptoms of dysarthria and lethargy indicate a potential medical emergency or brain injury, which should take precedence over the mental health assessment. It is important to first ensure the patient's physical well-being before proceeding with the mental health evaluation. Choice B is incorrect as skipping the language portion of the examination may overlook crucial information related to the patient's condition. Choice C is also incorrect as an in-depth speech evaluation may delay necessary medical interventions. Choice D is incorrect as assuming dysarthria is always linked to severe depression can lead to overlooking urgent medical needs.
Question 4 of 9
Which action should be performed first when assessing a hospitalized patient with shortness of breath?
Correct Answer: C
Rationale: The correct action is to obtain baseline information first, then do a complete assessment (Choice C). This is important as it allows the healthcare provider to gather initial vital signs and key information before proceeding with a thorough assessment. By obtaining baseline information first, the healthcare provider can assess the patient's current status and identify any urgent needs requiring immediate attention. This approach helps in prioritizing the assessment and subsequent interventions. Examining only the body areas related to the problem (Choice A) may lead to missing important clues to the patient's condition. Obtaining a thorough history and physical assessment from the family (Choice B) can provide valuable information but should not be the first step in assessing the patient's immediate needs. Examining the entire body to determine if the problem is linked to something else (Choice D) is not the most efficient approach as it may delay identifying and addressing the primary issue causing shortness of breath.
Question 5 of 9
The nurse is using a stethoscope to listen for bowel sounds. What should the nurse ensure before using the stethoscope?
Correct Answer: B
Rationale: The correct answer is B: Check the room temperature. This is important because extreme temperatures can affect the accuracy of bowel sound assessment. Cold temperatures can cause vasoconstriction, leading to decreased bowel sounds, while warm temperatures can lead to increased sounds due to increased blood flow. Choice A (Clean the stethoscope before use) is important for infection control but not directly related to ensuring accurate bowel sound assessment. Choice C (Place the stethoscope directly on the skin) is incorrect as bowel sounds are auscultated through clothing. Choice D (Use a hand sanitizer after use) is important for hand hygiene but not necessary before using the stethoscope for bowel sounds.
Question 6 of 9
What is the priority nursing action for a client with severe dehydration?
Correct Answer: A
Rationale: The correct answer is A: Administer IV fluids. The priority nursing action for a client with severe dehydration is to restore fluid volume to maintain vital organ function. Administering IV fluids is crucial in rapidly replenishing lost fluids and electrolytes. Corticosteroids (choice B) are not indicated for dehydration. Re-administering IV fluids (choice C) is redundant. Administering analgesics (choice D) is not a priority in the management of severe dehydration.
Question 7 of 9
Which of the following should be the nurse's priority when caring for a client who is receiving a blood transfusion?
Correct Answer: B
Rationale: The correct answer is B: Administer fluids. Administering fluids is the priority when caring for a client receiving a blood transfusion to prevent circulatory overload. Vital signs (A) should be monitored before and after the transfusion but are not the priority. Monitoring for transfusion reactions (C) is important but comes after administering fluids. Obtaining a blood sample (D) is not a priority during a blood transfusion. Administering fluids ensures adequate hydration and prevents complications during the transfusion process.
Question 8 of 9
What should be the nurse's first action when a client develops chest pain after surgery?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. The first action should be to ensure the client's oxygenation as chest pain could indicate decreased oxygen supply. Administering oxygen helps improve oxygen levels and can be crucial in managing potential complications. Summary of other choices: B: Administering morphine may mask the pain but doesn't address the underlying issue. C: Administering anticoagulants is not appropriate as the cause of chest pain is not related to clotting. D: Applying a warm compress is not indicated and may delay proper assessment and intervention for the chest pain.
Question 9 of 9
What is the BMI of a client weighing 216 pounds with a height of 66 inches?
Correct Answer: C
Rationale: The correct answer is C, BMI indicates obesity (35). To calculate BMI, we use the formula BMI = (Weight in pounds / (Height in inches x Height in inches)) x 703. Plugging in the values (216 / (66 x 66)) x 703, we get a BMI of approximately 35. A BMI of 35 falls within the obesity category (BMI 30 or higher). Choice A is incorrect because a BMI of 35 is not within normal limits. Choice B is incorrect as a BMI of 27 would indicate overweight status, not obesity. Choice D is incorrect as the BMI calculated is higher than normal, not lower.