health assessment in nursing test bank

Questions 36

ATI RN

ATI RN Test Bank

health assessment in nursing test bank Questions

Question 1 of 5

A visiting nurse is making an initial home visit to a patient who has a number of chronic medical problems. Which type of database is most appropriate to collect in this setting?

Correct Answer: C

Rationale: The correct answer is C: A complete health database because of the nurse's primary responsibility for monitoring the patient's health. In this initial home visit, the nurse needs to gather comprehensive information about the patient's medical history, current health status, medications, allergies, and lifestyle factors to establish a baseline for ongoing care. This complete health database will help the nurse make informed decisions and provide personalized care. Choice A (follow-up database) is incorrect as it is used to evaluate changes over time, not for the initial assessment. Choice B (episodic database) is incorrect because the patient's chronic medical problems require a more comprehensive approach. Choice D (emergency database) is incorrect as it is used for urgent situations, not for routine assessments.

Question 2 of 5

A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?

Correct Answer: D

Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients. A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately. B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds. C: Examining for symmetry is important but not directly related to the optimal position for auscultation.

Question 3 of 5

A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:

Correct Answer: B

Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia. A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues. C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits. D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.

Question 4 of 5

The nurse notices that the patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:

Correct Answer: D

Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites. A: Bulla is a large fluid-filled blister, not a solid lesion. B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction. C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.

Question 5 of 5

A 90-year-old patient tells the nurse that he is unable to remember the names of the medications he is taking or what they are for. An appropriate response would be:

Correct Answer: D

Rationale: The correct answer is D because asking the patient's family to bring in the medications will ensure accurate identification and understanding of the medications. This step is crucial in ensuring the patient's safety and well-being. Choice A is incorrect as appearance alone may not provide accurate information. Choice B is dismissive and does not address the issue. Choice C focuses on duration rather than addressing the immediate concern of medication identification.

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