ATI RN
health assessment test bank Questions
Question 1 of 9
Which of the following statements is true regarding respect for differences?
Correct Answer: B
Rationale: The correct answer is B because conveying respect for differences helps build trust and encourages patients to share their perspectives openly. This fosters a positive patient-provider relationship and enhances communication. Choice A is incorrect as patients have unique behaviors. Choice C is incorrect as cultural expectations do not fully explain individual differences. Choice D is incorrect as expressing one's culture is not solely dependent on exposure to Canadian values.
Question 2 of 9
What should be done for a client who is post-op and develops a fever within the first 48 hours?
Correct Answer: B
Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.
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
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Correct Answer: A
Rationale: The correct answer is A: Breathing, pain, sleep. Prioritizing breathing is crucial as it is a life-threatening issue. Pain should be addressed next to ensure the patient's comfort and well-being. Sleep can be addressed last as it is a lower priority compared to breathing and pain. Prioritizing in this order ensures the patient's immediate needs are met first. Choice B is incorrect because sleep should not take precedence over pain when the patient is in acute pain. Choice C is incorrect because addressing sleep before breathing and pain can be detrimental to the patient's health. Choice D is incorrect because breathing should be the top priority over both pain and sleep.
Question 5 of 9
Critique the following statement made by the nurse: "I know it may be hard, but you should do what the doctor ordered because he/she is the expert in this field.'
Correct Answer: C
Rationale: The correct answer is C because the statement made by the nurse implies a power dynamic that can create dependency and inferiority in the patient, which is not conducive to a patient-centered approach. In a healthcare setting, it is important to empower patients to be active participants in their care decisions rather than being passive recipients. Encouraging patients to blindly follow orders without understanding or questioning can lead to poor outcomes and lack of patient engagement. Therefore, it is best to avoid making statements that reinforce hierarchical relationships and instead foster open communication and shared decision-making. The other choices are incorrect because: A: This choice focuses on bias, which is not the main issue at hand in this scenario. B: While healthcare team members are experts in their respective fields, the emphasis should be on collaborative decision-making rather than blind obedience. D: Using authority statements may be necessary in certain situations, but it does not address the potential harm of creating dependency and inferiority in the patient.
Question 6 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 7 of 9
Which is an inappropriate item in planning care for a severely neutropenic client?
Correct Answer: A
Rationale: The correct answer is A: Transfuse neutrophils. Neutrophil transfusion is not a standard treatment for neutropenia as neutrophils do not survive well outside the body. For the other choices: B: Excluding raw vegetables is correct to prevent infection. C: Avoiding rectal suppositories is correct to prevent mucosal injury. D: Prohibiting vases of fresh flowers is correct to prevent exposure to fungal spores. So, transfusing neutrophils is inappropriate as it is not a standard treatment for neutropenia.
Question 8 of 9
A nurse is caring for a patient with hypertension. The nurse should monitor for which of the following complications?
Correct Answer: D
Rationale: The correct answer is D. Hypertension can lead to various complications affecting the heart, kidneys, and brain. Monitoring for heart failure is crucial due to the increased workload on the heart. Chronic kidney disease is a common complication of hypertension, as the kidneys are sensitive to changes in blood pressure. Stroke is another significant risk due to the potential damage to blood vessels in the brain. Therefore, monitoring for all these complications is essential in managing a patient with hypertension. Other choices are incorrect as they do not encompass all possible complications of hypertension.
Question 9 of 9
A patient is at the clinic to have her blood pressure checkeShe has been coming to the clinic weekly since her medications were changed 2 months ago. The nurse should:
Correct Answer: A
Rationale: Rationale: 1. Collecting a follow-up database ensures up-to-date information. 2. It allows for monitoring of medication effectiveness and any new symptoms. 3. Checking the blood pressure is essential but needs current context. 4. Asking the patient to read her record may not provide all necessary updates. 5. The complete health history is crucial but obtaining it first may delay urgent blood pressure check.