ATI RN
health assessment test bank jarvis Questions
Question 1 of 9
What is the most important action when caring for a client with respiratory distress?
Correct Answer: A
Rationale: Administering oxygen is the most important action for a client with respiratory distress because it helps improve oxygen levels in the blood and supports breathing. Oxygen therapy can prevent hypoxia and reduce respiratory workload. Corticosteroids, bronchodilators, and analgesics may be beneficial in specific situations, but they are not the primary intervention for respiratory distress. Corticosteroids reduce inflammation, bronchodilators help open airways, and analgesics provide pain relief but do not directly address the underlying issue of inadequate oxygenation. Administering oxygen should always be the first priority in managing respiratory distress.
Question 2 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 3 of 9
A nurse is teaching a patient with a history of stroke about preventing future strokes. 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 once blood pressure is normal can lead to a rebound increase in blood pressure, increasing the risk of stroke. A patient with a history of stroke needs to continue taking medications as prescribed to maintain optimal blood pressure control. Statements A, B, and D are all indicative of good stroke prevention strategies, such as managing blood pressure, limiting alcohol intake, and maintaining a healthy lifestyle.
Question 4 of 9
What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
Question 5 of 9
A nurse is taking health history from a patient. The nurse observes the patient's nonverbal behaviors such as hand wringing, avoiding eye contact, and shifting in the seat. Which of the following would be an appropriate response by the nurse?
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and addresses the patient's potential emotions directly. By asking if the patient feels nervous or worried about the pregnancy, the nurse acknowledges the observed nonverbal behaviors and opens the door for the patient to express their feelings. This approach shows sensitivity and may help the patient feel understood and supported. Choice A is incorrect because directly asking the patient to explain what they are feeling might come off as intrusive and could make the patient uncomfortable. Choice B is not ideal as remaining silent may lead to missed opportunities for the patient to share their concerns. Choice D, while important, does not address the specific nonverbal cues observed and may not prompt the patient to open up about their emotions.
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
When formulating diagnostic statements, what would the nurse use?
Correct Answer: D
Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.
Question 8 of 9
A nursing diagnosis made by a critical thinker using a dynamic nursing process would identify the actual problem and would also:
Correct Answer: B
Rationale: The correct answer is B because critical thinking involves anticipating potential issues to provide proactive care. By predicting potential problems, nurses can prevent complications and tailor interventions accordingly. This step is essential in the nursing process to ensure comprehensive and effective care. Continuing to reassess (A) is important but not the primary focus of a nursing diagnosis. Checking the appropriateness of goals (C) is crucial but comes after identifying the problem and predicting potential issues. Modifying the diagnosis if necessary (D) is a part of critical thinking but not the immediate next step after identifying the actual problem.
Question 9 of 9
What should the nurse do first when caring for a client with a suspected spinal cord injury?
Correct Answer: A
Rationale: The correct answer is A: Immobilize the spine. This is the first priority because it helps prevent further injury to the spinal cord. By immobilizing the spine, the nurse ensures that any movement doesn't worsen the existing injury. Placing the client in a supine position (B) can be done after immobilization. Administering analgesics (C) should not be done before assessing the extent of the injury. Assessing the airway (D) is important but should come after immobilizing the spine to prevent any unnecessary movement.