ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?
Correct Answer: D
Rationale: The correct answer is D: pain in the scapular region. This is because a herniated nucleus pulposus at the C4-C5 and C5-C6 interspaces typically results in pain radiating from the neck to the scapular region due to nerve compression at those levels. The other choices are incorrect as constant, throbbing headaches are not typically associated with this specific diagnosis, clonus in the lower extremities is more indicative of lower spinal cord involvement, and numbness of the face is not a common symptom of herniated discs at these levels.
Question 2 of 5
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
Correct Answer: B
Rationale:
Step 1: The scenario describes
Toni minimizing her visual problems, planning advanced degrees, seeking full-time jobs, and wanting more children.
Step 2:
Choice B is correct because it recognizes
Toni's behavior as a coping mechanism to deal with her illness.
Step 3: Minimizing visual problems and focusing on future goals can be a way for
Toni to maintain a positive outlook and cope with her challenges.
Step 4:
Choices A, C, and D are incorrect because they do not address
Toni's behavior as a coping mechanism.
Choice A mentions euphoria, which is not supported by the scenario.
Choice C and D do not acknowledge
Toni's coping mechanism but instead focus on different aspects like disease process and physical functioning.
Question 3 of 5
Which assessment action will help the nurse determine if the patient with Bell’s Palsy is receiving adequate nutrition?
Correct Answer: D
Rationale: The correct answer is D: Assess swallowing reflex. This is crucial for a patient with Bell's Palsy as it can affect their ability to swallow properly, leading to inadequate nutrition intake. By assessing the swallowing reflex, the nurse can determine if the patient is at risk of aspiration or difficulty in eating, which directly impacts their nutrition status. Monitoring meal trays (
A) may not provide accurate information on actual food intake. Checking weights (
B) only gives limited information on nutrition status. Measuring intake and output (
C) is important for fluid balance but may not directly reflect adequate nutrition intake.
Question 4 of 5
A nurse is directed to administer a hypotonic intravenous solution. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
Correct Answer: C
Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms.
Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.
Question 5 of 5
Which of the ff should qualify as an abnormal result in a Romberg test?
Correct Answer: B
Rationale:
Step-by-step rationale:
1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception.
2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal.
3. Hypotension (choice
A) is not directly related to the Romberg test.
4. Sneezing and wheezing (choice
C) are unrelated to the test.
5. Excessive cerumen in the outer ear (choice
D) does not affect proprioception.
Summary:
Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test.
Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.