ATI RN
test bank foundations of nursing Questions
Question 1 of 5
The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying?
Correct Answer: A
Rationale: The correct answer is A: Depression. In the context of the stages of death and dying proposed by Elisabeth K�bler-Ross, a patient exhibiting signs of loss, grief, and intense sadness is likely in the depression stage. This stage involves feelings of hopelessness, despair, and sorrow as the patient comes to terms with the reality of their situation. Denial (choice B) is characterized by a refusal to accept the diagnosis, anger (choice C) involves feelings of resentment and frustration, and resignation (choice D) signifies a sense of acceptance and peace. In this scenario, the patient's emotional state aligns most closely with depression, indicating a deep sense of sadness and mourning.
Question 2 of 5
A patient has fallen several times in the pastweek when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse ismostappropriate in correcting this urinaryproblem?
Correct Answer: A
Rationale: The correct answer is A: Limit fluid and caffeine intake before bed. This recommendation addresses the issue of nocturia (frequent urination at night) by reducing the amount of urine produced before bedtime, therefore decreasing the need to get up during the night. Caffeine is a diuretic, so limiting its intake can also help reduce the frequency of urination. Choices B, C, and D do not directly address the underlying cause of nocturia and falling. Leaving the bathroom light on (choice B) may help with visibility but does not address the urinary problem. Kegel exercises (choice C) focus on pelvic floor muscles, not bladder muscles. Clearing the path to the bathroom (choice D) can prevent falls but does not address the urinary issue.
Question 3 of 5
A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?
Correct Answer: C
Rationale: The correct answer is C: Promote positive nitrogen balance. In a postsurgical patient, promoting positive nitrogen balance is crucial for wound healing and tissue repair. This goal helps prevent muscle wasting and promotes overall recovery. A: Reduce dependent nitrogen balance is incorrect as it does not address the need for positive nitrogen balance in wound healing. B: Maintain negative nitrogen balance is incorrect because negative nitrogen balance indicates a loss of protein stores, which is detrimental for healing. D: Facilitate neutral nitrogen balance is incorrect as it does not actively support the increased protein needs for wound repair.
Question 4 of 5
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer�Betke test is positive. Based on this information, you anticipate that
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer�Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby. Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer�Betke test result indicating fetal-maternal hemorrhage.
Question 5 of 5
During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patients signs and symptoms are suggestive of what health problem?
Correct Answer: C
Rationale: Rationale: 1. Erythema of nipple/areola in one breast can be a sign of Paget's disease, a rare form of breast cancer. 2. Paget's disease may also present with itching, tingling, or a burning sensation in the affected area. 3. Referring the patient promptly is crucial for early detection and appropriate management. 4. Peau d'orange (A) is a sign of advanced breast cancer, not typically presenting with erythema alone. 5. Nipple inversion (B) may be benign or related to other conditions, not typically presenting with erythema. 6. Acute mastitis (D) presents with breast pain, warmth, swelling, and fever, but not typically with isolated erythema of the nipple/areola.
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