ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
What is the primary purpose of the outcome identification and planning step of the nursing process?
Correct Answer: D
Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis).
Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.
Question 2 of 5
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (
A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (
B) and profuse sweating (
D) are not typically associated with HHNK coma.
Question 3 of 5
The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
Correct Answer: D
Rationale: The correct answer is D, decreased body temperature and cold intolerance, because these are classic signs of hypothyroidism due to decreased thyroid hormone levels. The body's metabolism slows down, leading to a lower core body temperature and reduced ability to tolerate cold. Exophthalmos and conjunctival redness (choice
A) are associated with hyperthyroidism. Flushed, warm, moist skin (choice
B) is indicative of hyperthyroidism as well, due to increased metabolic rate. A systolic murmur at the left sternal border (choice
C) is not a common finding in hypothyroidism.
Question 4 of 5
Which of the following nursing interventions is correctly categorized as collaborative?
Correct Answer: D
Rationale: The correct answer is D because monitoring a client's response to an intervention initiated by another healthcare professional is a collaborative nursing intervention. This involves working together with other healthcare team members to assess the client's progress and adjust care as needed. It promotes continuity of care and ensures that the client's needs are met effectively.
A: Administering medications is typically an independent nursing intervention.
B: Ordering a low-sodium diet is within the scope of a nurse's independent practice.
C: Providing health education is often considered an independent nursing intervention unless it involves collaboration with other team members.
In summary, choice D is the correct answer as it exemplifies collaborative care within a healthcare team.
Question 5 of 5
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
Correct Answer: D
Rationale:
Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension.
Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension.
Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure.
Step 4: The other options (A, B, and
C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.