ATI RN
jarvis health assessment test bank Questions
Question 1 of 5
When percussing over the ribs of a patient, the nurse notes a dull sounThe nurse would:
Correct Answer: A
Rationale: The correct answer is A because the dull sound over the ribs is a normal finding due to the presence of underlying solid structures such as the liver or spleen. Repositioning the hands or using more force is unnecessary as it won't change the nature of the sound. Referring the patient for additional investigation (choice D) is not warranted as this finding is commonly expected during percussion over the ribs.
Question 2 of 5
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 3 of 5
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 4 of 5
Which of the following is appropriate for the nurse to say near the end of the interview?
Correct Answer: B
Rationale: The correct answer is B: "Is there anything else you would like to mention?" This question allows the patient to share any additional information or concerns before concluding the interview. It shows empathy and ensures thorough communication. Choice A is not the best option as it may suggest the nurse is rushing or has overlooked something. Choice C is inappropriate as it lacks empathy and may make the patient feel rushed. Choice D is also incorrect as it shifts the focus to a different topic instead of allowing the patient to express any remaining issues or questions.
Question 5 of 5
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.