ATI RN
health assessment exam 1 test bank Questions
Question 1 of 9
When a nurse is performing a neurological assessment, which of the following is most important to assess first?
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
Question 2 of 9
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for signs of which of the following complications?
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease. B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely. C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication. D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.
Question 3 of 9
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial. Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
Question 4 of 9
A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over her other clothes. Her hair is dyed pink with black streaks. She has several piercings in her nares and ears and is wearing an earring on her eyebrow and heavy black makeup. The nurse concludes that:
Correct Answer: D
Rationale: The correct answer is D because more information should be gathered to assess the situation appropriately. The woman's appearance may suggest alternative lifestyles or personal expression rather than mental health issues. It is essential to avoid assumptions based solely on appearance and gather a comprehensive history to understand her choices. Options A and B are dismissive and judgmental, failing to consider the complexity of human behavior. Option C is incorrect as the presented information does not provide enough evidence to diagnose manic syndrome. In summary, option D is the most logical and ethical approach to understanding the woman's situation without making unfounded assumptions.
Question 5 of 9
A nurse is providing education to a patient with hypertension. Which of the following statements by the patient indicates the need for further education?
Correct Answer: C
Rationale: The correct answer is C. This statement indicates a misunderstanding because stopping medication once blood pressure is normal can lead to a relapse of hypertension. Step 1: Medication management is crucial for long-term control of hypertension. Step 2: Stopping medication abruptly can cause blood pressure to rise again. Step 3: Regular monitoring, limiting sodium intake, and exercising are all important aspects of hypertension management. Summary: Choices A, B, and D demonstrate good understanding of hypertension management, while choice C shows a need for further education on the importance of continued medication use.
Question 6 of 9
When a nurse is performing a neurological assessment, which of the following is most important to assess first?
Correct Answer: C
Rationale: The correct answer is C: Patient's level of consciousness. Assessing the patient's level of consciousness is crucial in a neurological assessment as it provides immediate information on the overall function of the brain. Changes in consciousness can indicate serious neurological issues such as head injuries or stroke. It is essential to prioritize assessing consciousness first to determine the urgency of the situation. Assessing reflexes (A), cranial nerve function (B), and pupil response (D) are also important in a neurological assessment but come after assessing the patient's level of consciousness, as they provide more specific and detailed information about the neurological status.
Question 7 of 9
A nurse is caring for a patient who is post-operative following an appendectomy. The nurse should prioritize which of the following in the immediate post-operative period?
Correct Answer: C
Rationale: The correct answer is C, monitoring vital signs and fluid status, because it is crucial for assessing the patient's immediate post-operative condition and detecting any signs of complications like hemorrhage or shock. This step ensures early intervention if any issues arise, promoting patient safety and recovery. Administering pain medication (A) is important but not the top priority. Encouraging early ambulation (B) and providing wound care (D) are also essential but come after ensuring the patient's vital signs and fluid status are stable.
Question 8 of 9
A nurse is assessing a patient with chronic kidney disease. The nurse should prioritize which of the following lab values?
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine levels. In patients with chronic kidney disease, monitoring serum creatinine levels is crucial because it reflects kidney function. An increase in creatinine levels indicates worsening kidney function. Hemoglobin levels (B) are important in assessing anemia, common in CKD, but not the priority. White blood cell count (C) and platelet count (D) may indicate infection or bleeding, respectively, but are not specific to kidney function in this context.
Question 9 of 9
A 32-year-old female patient complains that she has noticed several small, slightly raised, bright-red dots on her chest. On examination, the nurse thinks that the spots are probably:
Correct Answer: C
Rationale: The correct answer is C: Senile angiomas. Senile angiomas are common benign growths of small blood vessels that appear as bright-red dots on the skin, commonly seen in older individuals. In this case, the patient is 32 years old, which is relatively young for an appearance of senile angiomas, but still within the possible age range. Anasarca (A) is generalized edema, not related to the described skin condition. Scleroderma (B) is a connective tissue disorder characterized by skin thickening and not associated with bright-red dots. Latent myeloma (D) is a type of bone marrow cancer and not related to the skin findings described.