ATI RN
jarvis physical examination and health assessment test bank Questions
Question 1 of 5
The purpose of the expanded assessment when using the LAPSS is to:
Correct Answer: C
Rationale: The purpose of the expanded assessment when using the LAPSS is to determine whether there are other possible causes of the patient's signs and symptoms. This is because LAPSS primarily focuses on identifying stroke symptoms, so the expanded assessment helps rule out other potential conditions. Option A is incorrect because LAPSS does not primarily assess circulation. Option B is incorrect because LAPSS is not specifically designed to determine compartment syndrome. Option D is incomplete and does not provide any information to support it as the correct answer.
Question 2 of 5
A 79-year-old client is admitted with pneumonia. Which symptom would most likely indicate the need for further evaluation?
Correct Answer: B
Rationale: The correct answer is B: Chest pain and pleuritic breathing. This indicates possible complications like pleurisy or pleural effusion, requiring further evaluation. A: Persistent cough with sputum production is common in pneumonia. C: Shortness of breath is a typical symptom of pneumonia. D: Fever and chills are also common in pneumonia. However, chest pain and pleuritic breathing are more indicative of potential complications that may require immediate attention.
Question 3 of 5
What term describes the rhythmic, involuntary contractions of a muscle that can occur in patients with neurological conditions, such as cerebral palsy?
Correct Answer: B
Rationale: The correct answer is B: Clonus. Clonus is a series of rhythmic, involuntary muscle contractions and relaxations that occur due to an abnormal response in the stretch reflex. In patients with neurological conditions like cerebral palsy, clonus is often observed due to increased muscle tone. Tremor (A) is a rhythmic shaking movement, not specifically associated with muscle contractions. Spasm (C) is a sudden, involuntary muscle contraction that is not typically rhythmic. Fasciculation (D) is a brief, spontaneous contraction of a small number of muscle fibers, not the rhythmic pattern seen in clonus.
Question 4 of 5
The nurse is caring for an older adult who is having difficulty with swallowing. Which intervention should the nurse implement to prevent aspiration?
Correct Answer: B
Rationale: The correct answer is B: Provide thickened liquids and soft foods. This intervention helps prevent aspiration by reducing the risk of food or liquids entering the airway. Thickened liquids are easier to control while swallowing, decreasing the chance of aspiration. Soft foods are also easier to chew and swallow, further reducing the risk. Choice A is incorrect because eating quickly can increase the risk of choking and aspiration. Choice C is incorrect as lying down after meals can actually increase the risk of aspiration. Choice D is incorrect as large meals can increase the likelihood of swallowing difficulties and aspiration.
Question 5 of 5
An 85-year-old woman with congestive heart failure and frailty asks about hastening her death. Which of the following is legal throughout the United States?
Correct Answer: C
Rationale: The correct answer is C: Voluntary stopping of eating and drinking. This is legal throughout the United States because it is considered a patient's right to refuse food and water, even if it may lead to death. This decision is based on the principle of patient autonomy and respects the patient's wishes. Euthanasia (A) involves actively causing death, which is illegal in the United States. Palliative sedation (B) is providing medication to relieve suffering, but not with the intention of hastening death. Physician-assisted death (D) involves a physician providing medication for a patient to self-administer to end their life, which is not legal in all states.
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