ATI RN
health assessment test bank jarvis Questions
Question 1 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.
Question 2 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 3 of 9
How many teeth should an 18-month-old child have?
Correct Answer: C
Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.
Question 4 of 9
While obtaining the history from the mother of a 2-year-old with pneumonia, the nurse asks the mother if she smoked or used drugs during her pregnancy. Her response is, "What does that have to do with pneumonia?" How would the nurse answer her question?
Correct Answer: D
Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions. Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.
Question 5 of 9
What is the most effective action when a client presents with acute shortness of breath and a history of COPD?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.
Question 6 of 9
A patient with heart failure tells the nurse, "I can't breathe very well at night." The nurse should ask:
Correct Answer: A
Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.
Question 7 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 8 of 9
Which information should a nurse recognize as a contraindication for hormone replacement therapy?
Correct Answer: D
Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.
Question 9 of 9
Which of the following foods is a complete protein?
Correct Answer: B
Rationale: The correct answer is A: Eggs. Eggs are considered a complete protein because they contain all 9 essential amino acids required by the human body. This makes them a high-quality protein source. Corn (B), peanuts (C), and sunflower seeds (D) are not complete proteins as they lack one or more of the essential amino acids. Corn is deficient in lysine, peanuts are deficient in methionine, and sunflower seeds are deficient in lysine. Therefore, only eggs provide all the essential amino acids necessary for optimal health and proper bodily functions.