HEALTH ASSESSMENT EXAM (FUNDAMENTALS)
ATI HEALTH ASSESSMENT EXAM (FUNDAMENTALS)
Total Questions : 51
Showing 10 questions Sign up for moreA nurse manager in a community clinic is planning an in-service to increase staff nurses' knowledge on cultural diversity in health care. Which of the following information should the nurse manager include in the presentation?
(Select All that Apply)
Explanation
A. Cultural beliefs, values, and practices can significantly impact an individual's health behaviors and adherence to medical recommendations.
C. Different cultures may have varied understandings of health and illness, which can affect how they perceive symptoms, seek treatment, and interact with healthcare providers.
D. Healthcare decisions may involve family members, elders, or other community members. Understanding these dynamics is essential for nurses to effectively engage with patients and their families in care planning and decision-making processes.
E. Cultural factors can influence how individuals access and utilize healthcare services. Some cultures may prioritize traditional healing practices or seek care from alternative sources before turning to Western medicine.
B. Power imbalances can actually hinder effective communication and care delivery, especially in cross- cultural encounters
A nurse is completing the intake health assessment at a clinic. Which of the following is the priority action for the nurse to take?
Explanation
Identifying the client's primary health issue or reason for seeking care, the nurse can prioritize the assessment and subsequent care interventions accordingly. This approach ensures that urgent or important health issues are addressed promptly, contributing to patient safety and satisfaction.
A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?
Explanation
Adaptive feeding devices are specifically designed to assist individuals with limited hand movement in feeding themselves more independently. These devices can include utensils with larger handles, specialized grips, or devices that stabilize food items for easier manipulation. Providing such devices can enhance the client's ability to feed themselves and promote autonomy in their daily activities.
A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?
Explanation
Anxiety is a subjective emotional state characterized by feelings of worry, nervousness, or unease. If the client reports feeling anxious, this would be considered subjective because it is based on their own perception of their emotional state.
A. Alert refers to the client's level of consciousness and awareness of their surroundings.
B. Restlessness refers to a feeling of agitation or inability to stay still.
D. Pacing is an observable behavior where the client is walking back and forth in the room.
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?
Explanation
Gloves are typically the first piece of PPE to be removed after providing care. This helps prevent the spread of pathogens from contaminated gloves to other surfaces or body parts. Gloves should be removed carefully to avoid touching the outside surface, which may be contaminated. This should be followed by face shield, gown and mask in that order.
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)
Explanation
A. In cases of dehydration, urine output may decrease, resulting in a more concentrated urine that appears darker in color. Therefore, the nurse may expect the urine to be darker in color.
B. Tachycardia is more commonly observed due to dehydration and the body's compensatory mechanisms.
C. Poor skin turgor is a classic sign of dehydration and may be observed in clients with vomiting and diarrhea.
D. Flat neck veins aretypically associated with dehydration. This occurs due to reduced intravascular volume leading to collapse of the veins.
E. Hypotension is commonly associated with dehydration resulting from vomiting and diarrhea. Loss of fluids and electrolytes can lead to decreased blood volume and subsequent hypotension.
A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?
Explanation
Maintaining a nonjudgmental attitude allows the client to feel comfortable discussing their alcohol use without fear of criticism or condemnation. It also helps foster honest communication and promotes engagement in the treatment process.
A. It's important to balance sympathy with professionalism and maintain appropriate boundaries.
C. Expressing disapproval of the client's substance abuse can be counterproductive and may hinder the therapeutic relationship.
D. While it's important for the nurse to maintain professionalism and emotional boundaries, completely avoiding displaying any emotional response may come across as cold or detached.
A nurse is caring for a client who is postoperative. Nurses' Notes
0745:
Client awake and eating breakfast while watching the news on television. Client has hearing loss, does not wear hearing aid, and TV volume is loud. Rates pain as a 2 on a 0 to 10 pain scale.
Incisional dressing dry and intact. 1000:
Client ambulated in hallway with physical therapist. Client grimacing. appears upset and is guarding incisional site. Reports pain a 5 on a 0 to 10 pain scale. Opioid analgesic administered.
1045
Client resting with eyes closed and listening to music with earphones. Reports feeling "very sleepy after pain medication. Now rates pain as a 3 on a 0 to 10 pain scale.
Which of the following factors could present a barrier to the nurse effectively communicating with the client? (Select all that apply).
Explanation
The client's hearing deficit can certainly present a barrier to effective communication, as it may affect their ability to hear and understand verbal instructions or information provided by the nurse.
B. The loud volume of the client's television is not a barrier in this case as the client has hearing loss.
C. Having numerous visitors in the client's room can create distractions and make it challenging for the nurse to engage in private, focused communication with the client.
D. An increase in pain after ambulation can impact the client's ability to focus and engage in effective communication. The client may be preoccupied with managing their pain, which can hinder their receptiveness to communication from the nurse.
E. Adverse effects of opioid analgesic: Adverse effects of opioid analgesics, such as drowsiness or sedation, can impair the client's cognitive function and alertness, making it difficult for them to participate actively in communication with the nurse.
F. Using earphones while listening to music may create a physical barrier to communication, as it limits the nurse's ability to speak directly to the client or gain their attention.
A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?
Explanation
Amoxicillin-clavulanate is a combination antibiotic that contains amoxicillin, which belongs to the penicillin class of antibiotics. Because the child is allergic to penicillin, there is a potential cross-reactivity with amoxicillin, which could lead to an allergic reaction.
A, B, and D are not penicillin antibiotics and do not typically cross-react with penicillin allergies.
A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?
Explanation
Malnutrition typically leads to muscle wasting and weakness, including respiratory muscles. As a result, it is more common to see a decrease in vital capacity rather than an increase.
B. Malnutrition can lead to cognitive impairment and decreased mental status due to inadequate nutrient supply to the brain. Deficiencies in essential nutrients such as vitamins and minerals can affect cognitive function, memory, and concentration.
C. Malnutrition is more commonly associated with dry, rough, and scaly skin due to deficiencies in essential fatty acids and vitamins. Moist skin is not typically a finding associated with malnutrition.
D. Heat intolerance is a feature of hyperthyroidism that is not typically seen in malnutrition.
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