ATI RN
test bank for health assessment Questions
Question 1 of 5
Which goal should be set for a client at risk for nutritional problems?
Correct Answer: B
Rationale: The correct answer is B: Increase weight. For a client at risk for nutritional problems, increasing weight is crucial to improve overall health and address potential malnutrition. This goal focuses on restoring and maintaining a healthy weight, which is essential for proper functioning of the body and reducing the risk of various health issues. Promoting healthy nutritional practices (choice A) is important but may not address the immediate need for weight gain. Treating complications of malnutrition (choice C) is reactive rather than proactive. Increasing protein in the diet (choice D) is helpful but not comprehensive enough to address the overall nutritional needs of the client.
Question 2 of 5
What is the primary nutritional deficiency concern for strict vegetarians?
Correct Answer: B
Rationale: The correct answer is B: Vitamin B12. Strict vegetarians, especially those who exclude all animal products, are at risk of Vitamin B12 deficiency as it is primarily found in animal products. Vitamin C (A) deficiency is more common in those with poor fruit and vegetable intake. Vitamin E (C) deficiency is rare and usually seen in individuals with specific medical conditions. Magnesium (D) deficiency can occur in individuals with poor dietary intake or certain medical conditions, but it is not the primary concern for strict vegetarians.
Question 3 of 5
What is the priority nursing intervention for a client with a deep wound infection?
Correct Answer: B
Rationale: The correct answer is B: Apply sterile dressings. This is the priority nursing intervention for a client with a deep wound infection because it helps prevent further contamination and promotes wound healing. Sterile dressings create a barrier against external pathogens and keep the wound environment clean, which is crucial in managing infections. Administering IV antibiotics (choice A) may be necessary but treating the wound first is essential. Applying heat to the wound (choice C) can worsen the infection by promoting bacterial growth. Administering IV fluids (choice D) may be needed for hydration but is not the priority in managing a deep wound infection.
Question 4 of 5
Which sign might a nurse observe in a client with a high ammonia level?
Correct Answer: A
Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.
Question 5 of 5
What should the nurse do when caring for a client who is experiencing an anaphylactic reaction?
Correct Answer: A
Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps to quickly reverse severe symptoms by constricting blood vessels and opening airways. Administering corticosteroids (B) is not the immediate priority. Placing the client on their side (C) is important to prevent aspiration but does not address the anaphylactic reaction. Monitoring blood pressure (D) is essential but administering epinephrine takes precedence in managing anaphylaxis.
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