ati health assessment test bank

Correct Answer: A

Rationale: The correct answer is A: Severe headaches and blurred vision. Hypertension can lead to complications such as hypertensive crisis, causing symptoms like severe headaches and blurred vision due to increased pressure in the blood vessels. This can indicate a serious health issue requiring immediate medical attention. Weight loss and dizziness (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typically associated with hypertension complications. It's crucial for the nurse to educate the patient on recognizing these signs to prevent further health risks.

Correct Answer: C

Rationale: The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall. A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task. B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue. D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.

Correct Answer: A

Rationale: 1. Increased sputum production is a sign of COPD exacerbation due to worsening inflammation and mucus production. 2. Decreased respiratory rate is not typical in COPD exacerbation as patients often experience increased respiratory effort. 3. Low blood pressure is not a common sign of COPD exacerbation and is more likely related to other conditions or medications. 4. High fever is not a typical sign of COPD exacerbation and could indicate an infection or other underlying issue.

Correct Answer: C

Rationale: The correct answer is C: Pneumonia. The patient's symptoms of shortness of breath and cough with thick, green sputum suggest an acute infection in the lungs. Pneumonia is characterized by inflammation and infection of the lung tissue, leading to symptoms such as productive cough, shortness of breath, and sputum production. It is a serious condition that requires prompt treatment with antibiotics. A: Asthma typically presents with wheezing, chest tightness, and shortness of breath triggered by certain stimuli, but not usually with thick, green sputum. B: Bronchitis is inflammation of the bronchial tubes, characterized by cough with clear or slightly discolored sputum, not typically thick and green. D: Pulmonary embolism is a blockage in the arteries of the lungs, causing sudden shortness of breath and chest pain, but not usually associated with green sputum production.

Correct Answer: B

Rationale: The correct answer is B: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, improves circulation, aids in lung expansion, and promotes faster recovery. Pain management is important but encouraging mobility is a priority. Administering IV antibiotics is not necessary unless there is an infection present. Monitoring for signs of deep vein thrombosis is important but encouraging ambulation is a proactive approach to prevent its occurrence.