ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
The nurse will monitor J.E. for the following signs and symptoms:
Correct Answer: A
Rationale: The correct answer is A.
1. Change in level of consciousness is crucial in assessing neurological status.
2. Tachypnea indicates possible respiratory distress or oxygenation issues.
3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion.
4. Petechiae can be a sign of bleeding disorders or sepsis.
Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms.
Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E.
Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.
Question 2 of 5
Which of the ff nursing actions is helpful for older clients who are experiencing lens changes associated with aging?
Correct Answer: D
Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life.
A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging.
B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions.
C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.
Question 3 of 5
Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action.
Choice A is incorrect because emergency surgery should not be anticipated without further assessment.
Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation.
Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.
Question 4 of 5
Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:
Correct Answer: A
Rationale:
Correct
Answer: A: Cover wound with moist sterile dressing
Rationale:
1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing.
2. Moist dressing prevents the wound from drying out and minimizes the risk of infection.
3. The moist environment supports healing by promoting cell growth and preventing tissue damage.
4. It protects the exposed bowel from further injury and contamination.
Summary:
B: Finding out how this happened is important but not an immediate priority for patient care.
C: Placing sterile dry gauze can lead to the wound drying out and hinder healing.
D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.
Question 5 of 5
Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.
Correct Answer: C
Rationale: The correct answer is C: 5th cranial nerve. Tic douloureux, also known as trigeminal neuralgia, is characterized by severe facial pain. The trigeminal nerve, the 5th cranial nerve, is responsible for sensory input from the face. This nerve is commonly affected in cases of tic douloureux, leading to sharp, shooting pain in the face.
Choices A, B, and D are incorrect because the 1st cranial nerve (olfactory nerve), 7th cranial nerve (facial nerve), and 8th cranial nerve (vestibulocochlear nerve) are not typically associated with the symptoms of tic douloureux.