foundations of nursing test bank

Questions 100

ATI RN

ATI RN Test Bank

foundations of nursing test bank Questions

Question 1 of 5

An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient�s plan of care?

Correct Answer: B

Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.

Question 2 of 5

A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?

Correct Answer: A

Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome. Choices B, C, and D are incorrect. B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome. C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome. D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these

Question 3 of 5

An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient�s plan of care?

Correct Answer: B

Rationale: Correct Answer: B - Urge urinary incontinence Rationale: 1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence. 2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage. Incorrect Choices: A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void. C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis. D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.

Question 4 of 5

A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?

Correct Answer: B

Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing. Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.

Question 5 of 5

A child has been diagnosed with a severe walnut allergy after suffering an anaphylactic reaction. What is a priority for health education?

Correct Answer: B

Rationale: The correct answer is B: The need for the parents to carry an epinephrine pen. This is the priority for health education because in case of another anaphylactic reaction to walnuts, immediate administration of epinephrine can be life-saving. Immunotherapy (choice A) is not the primary focus in an emergency situation. Maintaining immunization status (choice C) is important but not as critical as having an epinephrine pen. Avoiding high potential allergens (choice D) is important but having an epinephrine pen takes precedence in managing severe allergic reactions.

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