ATI RN
Introduction to Community Health Nursing Questions
Question 1 of 5
While assessing an older adult patient, the nurse notes jugular venous distention (JD) 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 (JD) indicates increased pressure in the right atrium. Step 2: When the head of the bed is elevated, gravity helps blood return to the right side of the heart. Step 3: If JD is present with head elevation, it suggests that the right atrial pressure is elevated. Step 4: Elevated right atrial pressure often indicates heart failure or fluid overload. Step 5: Therefore, the correct answer is C: Increased right atrial pressure. Summary: A: Decreased fluid volume is incorrect because JD suggests fluid overload, not decreased volume. B: Jugular vein atherosclerosis is incorrect as JD is not typically associated with atherosclerosis. D: Incompetent jugular vein valves is incorrect as JD is more likely due to increased pressure than valve incompetence.
Question 2 of 5
An older adult patient who had a mitral valve replacement with a mechanical valve is taking warfarin. What should the nurse include in discharge teaching?
Correct Answer: C
Rationale: The correct answer is C: Need for frequent laboratory blood testing. For a patient on warfarin with a mechanical valve, regular monitoring of the international normalized ratio (INR) is essential to ensure the medication's effectiveness and prevent complications like clotting or bleeding. Incorrect choices: A - Aspirin is not recommended with warfarin due to increased bleeding risk. B - Knowing how to take radial pulse is not directly related to warfarin therapy. D - Avoiding physical activity is not necessary; instead, patients should engage in regular, moderate exercise unless advised otherwise by a healthcare provider.
Question 3 of 5
A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s compensatory mechanisms?
Correct Answer: A
Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client has metabolic acidosis indicated by a low pH and low HCO3 levels. The PaCO2 is low, which is not expected in metabolic acidosis. Therefore, the respiratory system is compensating by decreasing PaCO2 through increased rate and depth of respirations to help normalize the pH. Increased urinary output (choice B) and increased thirst and hunger (choice C) are not directly related to compensatory mechanisms for acid-base imbalances. Increased release of acids from the kidneys (choice D) would exacerbate the acidosis rather than compensate for it.
Question 4 of 5
The nurse understands that which type of immunity is the longest acting?
Correct Answer: C
Rationale: The correct answer is C: Natural active immunity. This type of immunity is the longest acting because it results from the body's exposure to a pathogen, leading to the production of memory cells that provide long-lasting protection. Natural active immunity involves the immune system responding to an actual infection or exposure to a pathogen, which triggers the production of antibodies and memory cells for future protection. In contrast, artificial active immunity (choice A) involves vaccines, which may require booster shots for long-lasting protection. Inflammatory response (choice B) is not a type of immunity but rather a non-specific defense mechanism against pathogens. Natural passive immunity (choice D) is short-lived and acquired from maternal antibodies, providing temporary protection.
Question 5 of 5
After a stroke, a patient is having difficulty swallowing. The nurse may make a referral to what member of the healthcare team?
Correct Answer: B
Rationale: The correct answer is B: speech therapist. Speech therapists specialize in evaluating and treating swallowing difficulties (dysphagia) after a stroke. They can provide techniques and exercises to improve swallowing function. Physical therapists focus on mobility and strength, social workers address psychosocial needs, and respiratory therapists manage breathing-related issues. However, in this case, the primary concern is swallowing dysfunction, making the speech therapist the most appropriate referral.