health assessment test bank jarvis

Questions 84

ATI RN

ATI RN Test Bank

health assessment test bank jarvis Questions

Question 1 of 5

While obtaining the history from the mother of a 2-year-old with pneumonia, the nurse asks the mother if she smoked or used drugs during her pregnancy. Her response is, "What does that have to do with pneumonia?" How would the nurse answer her question?

Correct Answer: D

Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions. Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.

Question 2 of 5

What should be the nurse's first priority for a client with an open wound?

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Question 3 of 5

A nurse is caring for a patient with a history of heart failure. The nurse should monitor for which of the following signs of fluid overload?

Correct Answer: C

Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.

Question 4 of 5

A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should prioritize which of the following to prevent complications?

Correct Answer: D

Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.

Question 5 of 5

A nurse is teaching a patient with diabetes about managing diabetic neuropathy. Which of the following statements by the patient indicates the need for further education?

Correct Answer: B

Rationale: The correct answer is B: "I can wear tight shoes to avoid blisters." Tight shoes can increase pressure on the feet, leading to blisters and worsening neuropathy symptoms. A: Inspecting feet daily is important to catch any issues early. C: Walking barefoot can increase the risk of injuries. D: Maintaining blood glucose levels within target range is crucial for managing diabetic neuropathy. In summary, the incorrect choices either provide important preventive measures or focus on key aspects of diabetes management, while the correct choice suggests a harmful behavior that can exacerbate neuropathy symptoms.

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