ATI RN
jarvis health assessment test bank pdf reddit Questions
Question 1 of 9
Which physical finding indicates developmental dysplasia of the hip in an 11-12-month-old child?
Correct Answer: B
Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.
Question 2 of 9
What is the best method for a nurse to assess a client's pain level?
Correct Answer: A
Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.
Question 3 of 9
A nurse is teaching a patient with diabetes about the signs and symptoms of hypoglycemia. Which of the following symptoms should the patient be instructed to monitor for?
Correct Answer: B
Rationale: The correct answer is B: Shakiness and dizziness. Hypoglycemia is characterized by low blood sugar levels, leading to symptoms such as shakiness and dizziness. This is because the brain requires glucose for energy, and when levels drop too low, these symptoms can occur. Increased thirst and urination (A) are more indicative of hyperglycemia, where blood sugar levels are too high. Blurred vision and headaches (C) can be symptoms of both hyperglycemia and hypoglycemia but are less specific to hypoglycemia. Fatigue and weight loss (D) are not typical symptoms of hypoglycemia.
Question 4 of 9
A nurse is caring for a patient with diabetes who is receiving insulin. The nurse should be most concerned if the patient experiences:
Correct Answer: C
Rationale: The correct answer is C: Dizziness and shakiness. This indicates hypoglycemia, a potential side effect of insulin therapy. Dizziness and shakiness are classic signs of low blood sugar levels, which can be dangerous if left untreated. Headache and blurred vision (Option A) can occur with high blood sugar. Increased thirst and urination (Option B) are symptoms of hyperglycemia. Dry mouth and skin (Option D) are not immediate concerns related to insulin therapy.
Question 5 of 9
A nurse is providing education to a patient who is newly diagnosed with hypertension. Which of the following dietary changes should the nurse recommend to the patient?
Correct Answer: C
Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.
Question 6 of 9
A patient is found to have an irregular, jagged scar that is raised and red. The nurse would classify this as:
Correct Answer: B
Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.
Question 7 of 9
What is the nurse's first priority when caring for a client who is in respiratory distress?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.
Question 8 of 9
When the nurse is evaluating the reliability of a patient's responses, which of the following would be a correct assessment?
Correct Answer: B
Rationale: The correct assessment is B because providing consistent information indicates reliability. Drug abuse history (A) does not necessarily mean the patient is unreliable. Smiling (C) is not a reliable indicator. Refusal to answer specific questions (D) does not negate overall reliability.
Question 9 of 9
A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following interventions?
Correct Answer: B
Rationale: The correct answer is B because encouraging early ambulation is a priority post-operative intervention for a patient following a hip replacement. Early ambulation helps prevent complications such as blood clots, muscle weakness, and pneumonia. It also promotes circulation and aids in the patient's recovery. Administering pain medications (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial, but ambulation takes precedence. Providing wound care (D) is essential but can be done after ensuring the patient's mobility.