ATI RN
jarvis health assessment test bank Questions
Question 1 of 9
Which nursing diagnosis applies to a client stating they feel incomplete due to infertility?
Correct Answer: B
Rationale: The correct answer is B: Body Image Disturbance. Infertility can impact one's perception of self and body image, leading to feelings of incompleteness. This nursing diagnosis addresses the emotional distress related to altered self-perception. A: Risk for Self Harm is not directly related to the client's statement about feeling incomplete due to infertility. C: Ineffective Role Performance doesn't specifically address the client's feelings of incompleteness related to infertility. D: Powerlessness may not fully capture the client's emotional struggle with their body image and feelings of incompleteness due to infertility.
Question 2 of 9
What should the nurse do for a client with suspected hypovolemia and hypotension?
Correct Answer: A
Rationale: The correct answer is A - Administer IV fluids. This is the priority intervention for a client with suspected hypovolemia and hypotension as it helps to restore intravascular volume and improve blood pressure. IV fluids will address the underlying cause of hypotension by increasing circulating volume. Monitoring blood pressure (B) is important but administering IV fluids takes precedence. Administering corticosteroids (C) is not indicated for hypovolemia and hypotension. Administering oxygen (D) may be necessary if there is evidence of hypoxia, but addressing fluid volume status is the primary concern in this scenario.
Question 3 of 9
Which lab value is associated with decreased cardiovascular disease risk?
Correct Answer: A
Rationale: Step-by-step rationale: 1. High HDL cholesterol is associated with decreased cardiovascular disease risk. 2. HDL cholesterol helps remove LDL cholesterol from arteries, reducing plaque buildup. 3. This leads to lower risk of heart disease and stroke. 4. Low HDL cholesterol (choice B) is associated with increased risk. 5. Low total cholesterol (choice C) and low triglycerides (choice D) do not directly correlate with decreased cardiovascular disease risk. Summary: High HDL cholesterol is beneficial for cardiovascular health as it helps reduce plaque buildup in arteries. Low HDL cholesterol, low total cholesterol, and low triglycerides are not associated with decreased cardiovascular disease risk.
Question 4 of 9
What is the most effective action when a client with a history of stroke develops difficulty speaking?
Correct Answer: B
Rationale: The correct answer is B: Administer thrombolytics. Thrombolytics help dissolve blood clots, which may be causing the stroke. Administering thrombolytics promptly can improve blood flow to the brain, potentially reducing the severity of the stroke and its effects, including difficulty speaking. Calling for help (A) is important, but administering thrombolytics should be a priority. Performing a CT scan (C) may help confirm the type of stroke but may delay immediate treatment. Administering bronchodilators (D) is not indicated for difficulty speaking related to stroke.
Question 5 of 9
A nurse is teaching a patient about managing hypertension. Which of the following statements made by the patient would indicate the need for further education?
Correct Answer: B
Rationale: Step 1: Patient stating they can stop taking medication once BP is normal shows misunderstanding of hypertension as a chronic condition. Step 2: Hypertension requires long-term management even if BP is controlled temporarily. Step 3: Stopping medication abruptly can lead to BP spikes and complications. Step 4: Other choices (A, C, D) demonstrate good understanding and proactive approach to managing hypertension. Summary: Choice B is incorrect as it suggests discontinuation of medication, posing a risk to the patient's health. Choices A, C, and D show positive behaviors towards hypertension management.
Question 6 of 9
A nurse is caring for a patient with cirrhosis. The nurse should monitor for signs of which of the following?
Correct Answer: A
Rationale: Step 1: Cirrhosis can impair the liver's ability to store glycogen and produce glucose. Step 2: Liver dysfunction can lead to hypoglycemia due to decreased glycogen stores and gluconeogenesis. Step 3: Monitoring for hypoglycemia is crucial as it can result in serious complications. Step 4: Hyperglycemia (B) is less likely in cirrhosis as the liver's ability to regulate blood sugar is impaired. Step 5: Hypokalemia (C) and hyperkalemia (D) are less directly related to cirrhosis and are not the primary concerns in this case.
Question 7 of 9
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 8 of 9
What should be the nurse's first action when caring for a client with suspected meningitis?
Correct Answer: A
Rationale: The correct answer is A: Perform a lumbar puncture. This is the first action because diagnosing meningitis requires cerebrospinal fluid analysis obtained through a lumbar puncture. It helps identify the specific type of meningitis (bacterial, viral, or fungal) and guides appropriate treatment. Administering pain relief (B) or oxygen (C) may be necessary but not the initial priority. Administering antibiotics (D) should be based on the results of the lumbar puncture to ensure targeted therapy.
Question 9 of 9
What should the nurse do first when a client presents with symptoms of hypoglycemia?
Correct Answer: A
Rationale: The correct answer is A: Administer glucose. When a client presents with symptoms of hypoglycemia, the nurse should prioritize raising the blood sugar levels immediately to prevent further complications. Administering glucose helps to quickly address the low blood sugar levels and alleviate symptoms. Monitoring blood glucose (B) is important but not the first step in an acute situation. Administering insulin (C) would worsen hypoglycemia. Monitoring for arrhythmias (D) is not the primary concern when dealing with hypoglycemia.