ATI RN
health assessment test bank Questions
Question 1 of 9
Which of the following statements about the mental health examination is true?
Correct Answer: B
Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs. A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills. C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently. D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.
Question 2 of 9
In response to a question about use of alcohol, a patient asks the nurse why the nurse needs that information. What reason would the nurse give the patient?
Correct Answer: B
Rationale: The correct answer is B because alcohol can interact with medications and exacerbate certain medical conditions. The nurse needs this information to ensure the patient's safety and well-being. Choice A is incorrect because the question is not about the patient's reliability. Choice C is incorrect as it assumes the nurse is required to educate the patient about alcohol dangers. Choice D is incorrect because even without an obvious drinking problem, alcohol use can still impact the patient's health.
Question 3 of 9
Which intervention should the nurse implement for a client who is experiencing a seizure?
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.
Question 4 of 9
What should the nurse monitor when caring for a client receiving anticoagulant therapy?
Correct Answer: B
Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications. Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy. Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy. Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.
Question 5 of 9
Which fetal heart monitor pattern can indicate cord compression?
Correct Answer: A
Rationale: The correct answer is A: variable decelerations. Variable decelerations are abrupt decreases in fetal heart rate that vary in depth, duration, and timing, which can indicate cord compression. The variability in these decelerations suggests that the umbilical cord is being compressed intermittently. Early decelerations (B) are usually caused by head compression during contractions and mirror the contractions, not indicating cord compression. Bradycardia (C) is a slow heart rate, which can be caused by various factors but is not specific to cord compression. Tachycardia (D) is a fast heart rate, which can also be caused by various factors but is not typically associated with cord compression.
Question 6 of 9
What is the most appropriate action when a parent crosses their arms and legs during an interview?
Correct Answer: D
Rationale: The correct answer is D because crossing arms and legs can indicate defensiveness or discomfort, which may suggest the parent is uneasy discussing their son's treatment. This nonverbal cue could signal a need for empathy and sensitivity in communication. Choice A is incorrect as it overlooks the significance of body language. Choice B assumes comfort without considering the context. Choice C assumes tiredness without considering other possibilities. Understanding body language cues can help in building rapport and addressing concerns effectively.
Question 7 of 9
The nurse is caring for a patient who is a recent immigrant and has limited English proficiency. Which of the following is the best action the nurse should take?
Correct Answer: C
Rationale: The correct answer is C: Use a professional interpreter or translation services to communicate effectively. This is the best action because it ensures accurate communication and understanding between the nurse and the patient. Professional interpreters are trained to accurately convey information while respecting cultural nuances. Explanation for why the other choices are incorrect: A: Using medical jargon can confuse the patient further and hinder effective communication. B: Speaking loudly and slowly can come across as patronizing and does not address the language barrier. D: Relying on the patient's family for translation can lead to miscommunication or breaches of patient confidentiality.
Question 8 of 9
What term describes excessive stretching of a ligament, as seen in a client with a pulled ligament?
Correct Answer: B
Rationale: The correct answer is B: strain. A strain refers to excessive stretching or tearing of a muscle or tendon, not a ligament. A sprain (choice A) is the correct term for excessive stretching of a ligament. Subluxation (choice C) refers to partial dislocation of a joint, not a ligament injury. Distortion (choice D) is a general term that does not specifically describe ligament stretching. Therefore, the correct term for excessive stretching of a ligament is a sprain, making choice A the correct answer.
Question 9 of 9
A nurse is assessing a patient who has a history of deep vein thrombosis (DVT). Which of the following findings would be most concerning?
Correct Answer: C
Rationale: The correct answer is C: Shortness of breath and chest pain. This is most concerning because it could indicate a pulmonary embolism, a serious complication of DVT where a blood clot travels to the lungs. Shortness of breath and chest pain are signs of compromised respiratory and cardiac function. A: Pain and swelling in the leg are common symptoms of DVT but not as concerning as symptoms of a pulmonary embolism. B: Redness and warmth around the affected area are typical signs of inflammation associated with DVT but do not indicate a life-threatening complication like a pulmonary embolism. D: Pale skin and decreased pulse in the affected leg could be signs of compromised circulation due to DVT, but they are not as immediately life-threatening as symptoms of a pulmonary embolism.