ati health assessment test bank

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The nurse has just started an assessment of the newborn child of a woman of Vietnamese origin. Considering the mother's cultural background, which of the following statements about this examination is true? The mother:

  • A. Will be offended if the infant's fontanelles are examined.
  • B. Will be offended if the infant's diaper area is touched during the examination.
  • C. Would prefer to have the results of the examination communicated directly to her husband.
  • D. Would prefer to receive written report about her child's growth and development, rather than a verbal one.
Correct Answer: A

Rationale: The correct answer is A because in Vietnamese culture, touching or examining the fontanelles (soft spots on a baby's head) is considered disrespectful and potentially harmful. This is due to the belief that the fontanelles are fragile and touching them can impact the baby's health. It is crucial for the nurse to respect and be sensitive to the cultural beliefs and practices of the mother to establish trust and provide culturally competent care.

Choice B is incorrect because there is no specific cultural taboo in Vietnamese culture about touching the infant's diaper area during examination. Choice C is incorrect as assuming that the husband should be the primary communicator of medical information goes against the principle of patient autonomy. Choice D is incorrect as there is no indication that Vietnamese mothers prefer written reports over verbal communication regarding their child's growth and development.

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A nurse is caring for a patient with hypertension. The nurse should educate the patient to monitor for which of the following complications?

  • A. Severe headaches and blurred vision.
  • B. Weight loss and fatigue.
  • C. Increased appetite and tremors.
  • D. Nausea and vomiting.
Correct Answer: A

Rationale: The correct answer is A: Severe headaches and blurred vision. These symptoms can indicate a hypertensive crisis, a severe complication of hypertension. Headaches and blurred vision are signs of potentially dangerous high blood pressure levels. Weight loss and fatigue (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typical complications of hypertension and do not directly relate to the cardiovascular effects of high blood pressure. Monitoring for severe headaches and blurred vision is crucial for early detection and management of hypertensive crises.

A nurse is caring for a patient with a history of myocardial infarction. The nurse should prioritize which of the following interventions?

  • A. Administering pain medication.
  • B. Monitoring vital signs and oxygen saturation.
  • C. Encouraging deep breathing exercises.
  • D. Providing nutritional education.
Correct Answer: B

Rationale: The correct answer is B: Monitoring vital signs and oxygen saturation. This is the priority intervention because it allows the nurse to assess the patient's current cardiac status and detect any potential complications early. Monitoring vital signs provides crucial information on the patient's cardiovascular stability, while oxygen saturation levels indicate adequate tissue perfusion. Administering pain medication (A) can be important but not the priority. Deep breathing exercises (C) and providing nutritional education (D) are important but not as immediate as monitoring vital signs and oxygen saturation in a patient with a history of myocardial infarction.

A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to monitor for which of the following complications?

  • A. Severe headaches and blurred vision.
  • B. Weight loss and dizziness.
  • C. Increased appetite and tremors.
  • D. Nausea and vomiting.
Correct Answer: A

Rationale: The correct answer is A: Severe headaches and blurred vision. Hypertension can lead to complications such as hypertensive crisis, causing symptoms like severe headaches and blurred vision due to increased pressure in the blood vessels. This can indicate a serious health issue requiring immediate medical attention. Weight loss and dizziness (B), increased appetite and tremors (C), and nausea and vomiting (D) are not typically associated with hypertension complications. It's crucial for the nurse to educate the patient on recognizing these signs to prevent further health risks.

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of an exacerbation?

  • A. Increased sputum production.
  • B. Decreased respiratory rate.
  • C. Low blood pressure.
  • D. High fever.
Correct Answer: A

Rationale: 1. Increased sputum production is a sign of COPD exacerbation due to worsening inflammation and mucus production.
2. Decreased respiratory rate is not typical in COPD exacerbation as patients often experience increased respiratory effort.
3. Low blood pressure is not a common sign of COPD exacerbation and is more likely related to other conditions or medications.
4. High fever is not a typical sign of COPD exacerbation and could indicate an infection or other underlying issue.

The nurse is obtaining a history from a 30-year-old male patient and is concerned about the adequacy of his health promotion activities. Which one of the following questions would be appropriate in this situation?

  • A. "Do you perform testicular self-examinations?"
  • B. "Have you ever noticed any pain in your testicles?"
  • C. "Have you had any problems with passing urine?"
  • D. "Do you have any history of sexually transmitted infection?"
Correct Answer: A

Rationale: The correct answer is A: "Do you perform testicular self-examinations?" This question is appropriate as it addresses health promotion activities specific to the patient's age and gender, promoting early detection of testicular cancer.

Explanation:
1. Testicular self-examination is a key health promotion activity for men in their 20s and 30s.
2. It encourages self-awareness and early detection of abnormalities in the testicles.
3. Testicular cancer is most common in younger men, making this question relevant.
4. Options B, C, and D are not directly related to health promotion activities for a 30-year-old male.

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