ATI RN
foundation of nursing questions and answers Questions
Question 1 of 5
A patient who was pregnant had a spontaneous abortion at approximately 4 weeks� gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the patient presents at the clinic office complaining of �crampy� abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100?F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/minute (bpm), and respirations, 20 breaths per minute. Based on this assessment data, what does the nurse anticipate as a clinical diagnosis?
Correct Answer: B
Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.
Question 2 of 5
A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
Correct Answer: A
Rationale: The correct answer is A: Disturbed Body Image Related to Effects of Surgery. This nursing diagnosis is appropriate because the patient expresses concerns about feeling emasculated and a shell of a man after the surgery, indicating a disturbance in his body image. The patient's perception of how the surgery will affect his masculinity is a clear indication of body image disturbance. Choice B is incorrect because there is no mention of spiritual distress in the patient's statements. Choice C is incorrect as there is no indication that the patient will experience social isolation specifically related to the surgery. Choice D is incorrect as the patient's concerns are primarily related to his body image and not loneliness.
Question 3 of 5
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action?
Correct Answer: A
Rationale: The correct answer is A because instilling the medication in the conjunctival sac allows for direct absorption into the eye tissues. This method ensures that the medication reaches the target area for treating glaucoma effectively. Maintaining a supine position (choice B) or keeping the eyes closed (choice C) after administration does not enhance absorption and may lead to wasted medication. Applying the medication to the sclera (choice D) is incorrect as it does not target the specific area needed for treating glaucoma.
Question 4 of 5
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patients tumor, the nurse should implement measures to prevent what complication?
Correct Answer: A
Rationale: The correct answer is A: Falls. A cerebellar tumor can affect coordination and balance, leading to an increased risk of falls. Measures to prevent falls include maintaining a clutter-free environment, using assistive devices, and providing supervision. Choice B (Audio hallucinations) is incorrect as cerebellar tumors typically do not cause auditory hallucinations. Choice C (Respiratory depression) is incorrect as cerebellar tumors do not directly affect the respiratory system. Choice D (Labile BP) is incorrect as cerebellar tumors are not typically associated with blood pressure fluctuations.
Question 5 of 5
Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient?
Correct Answer: C
Rationale: The correct answer is C: Reduce environmental noise and distractions before communicating. This intervention is most likely to facilitate effective communication with a hearing-impaired patient because it creates an optimal environment for the patient to better focus on the communication. By reducing noise and distractions, the patient can more easily concentrate on the conversation and lip reading, if needed. This approach demonstrates sensitivity to the patient's needs and enhances the chances of successful communication. The other choices are incorrect because: A: Asking the patient to repeat what was said may cause frustration and does not address the environmental factors that can hinder communication. B: Standing directly in front of the patient to facilitate lip reading may help, but it does not address the impact of environmental noise and distractions on communication. D: Raising the voice to project sound at a higher frequency is not effective as it can distort speech and may not necessarily improve understanding for a hearing-impaired patient.
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