ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JVD) with the head of the patient’s bed elevated 45 degrees. What does this finding indicate?
Correct Answer: C
Rationale: Step 1: Jugular venous distention (JVD) is often indicative of increased pressure in the right atrium. Step 2: Elevating the head of the bed to 45 degrees helps accentuate JVD, making it easier to observe. Step 3: Increased right atrial pressure can be caused by conditions like heart failure or tricuspid valve regurgitation. Step 4: This finding is significant in older adults as they are more prone to cardiovascular issues. Summary: Choice A is incorrect as JVD typically indicates fluid overload, not decreased volume. Choice B is incorrect as atherosclerosis affects arteries, not veins. Choice D is incorrect as incompetent jugular vein valves would lead to backflow, not distention.
Question 2 of 5
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that do not apply.)
Correct Answer: A
Rationale: Step-by-step rationale: 1. Chest x-ray is not routinely scheduled annually for monitoring complications in type 2 diabetes. 2. Blood pressure monitoring is essential for assessing cardiovascular risk in diabetic patients. 3. Serum creatinine levels are checked annually to assess kidney function. 4. Urine for microalbuminuria is done annually to detect early signs of kidney damage. 5. Since chest x-ray is not directly related to diabetes complications, it is the correct answer. Summary: A is correct because chest x-ray is not a standard test for monitoring type 2 diabetes complications. B, C, and D are incorrect as they are essential for evaluating cardiovascular risk, kidney function, and early signs of kidney damage in diabetic patients.
Question 3 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: The correct answer is B: Place a patient with altered consciousness in a side-lying position. This position helps prevent aspiration by reducing the risk of regurgitated material entering the airway. Patients with altered consciousness are at higher risk of aspiration due to impaired protective airway reflexes. Placing them in a side-lying position helps maintain an open airway and facilitates drainage of secretions. Incorrect choices: A: Turning and repositioning an immobile patient every 2 hours is important for preventing pressure ulcers, not aspiration. C: Inserting a nasogastric tube for feeding does not directly prevent aspiration; it is a method of providing nutrition. D: Monitoring respiratory symptoms in an immunosuppressed patient is important for detecting infections but does not directly prevent aspiration.
Question 4 of 5
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Perform a test focused on a neurologic examination. The client's symptoms indicate potential neurological issues, such as vision difficulties and constant nasal drainage, which could be related to nerve damage from the nasal fracture. By performing a neurologic examination, the nurse can assess for any nerve involvement and determine the extent of the injury. This action is crucial in identifying any neurological complications and guiding appropriate treatment. Summary: A: Collecting nasal drainage does not address the client's neurological symptoms. B: Encouraging the client to blow his or her nose could exacerbate the nasal fracture and is not relevant to the neurological symptoms. D: Palpating the nose, face, and neck may help assess the extent of the fracture but does not address the neurological symptoms reported by the client.
Question 5 of 5
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
Correct Answer: B
Rationale: The correct answer is B: Notify the Rapid Response Team. Puffy face and swollen eyelids can indicate a potential airway obstruction, which is a medical emergency. Notifying the Rapid Response Team ensures prompt intervention and appropriate management. Assessing oxygen saturation (A) may be important but addressing the potential obstruction takes priority. Oxygenating with a bag-valve-mask (C) may worsen the obstruction. Palpating the skin of the upper chest (D) is not directly related to addressing the potential airway issue.