ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale:
Correct Answer: B: Ask about the chief concerns or problems.
Rationale:
1. This step follows setting the agenda to focus on patient's main issues.
2. Allows nurse to gather essential information for effective care.
3. Builds rapport and shows patient-centered approach.
Summary of other choices:
A: Introductions are typically done at the beginning of the interview.
C: Prematurely ending the interview may hinder rapport and information gathering.
D: Administering medications is not the immediate priority after setting the agenda.
Question 2 of 5
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
Correct Answer: C
Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.
Question 3 of 5
The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat.
A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation.
B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation.
D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.
Question 4 of 5
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
Correct Answer: C
Rationale:
Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood.
Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia.
Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome.
Step 4:
Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms.
Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.
Question 5 of 5
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.