ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis.
Explanation of other choices:
B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect.
C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location.
D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,
Question 2 of 5
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because observing for signs of brain injury is crucial in assessing a possible skull fracture. Signs may include altered mental status, headache, nausea, vomiting, and unequal pupil size.
Choice B is incorrect as hemorrhaging from the oral cavity may not always be present in skull fractures.
Choice C is incorrect as elevating the foot of the bed is not recommended for a possible skull fracture.
Choice D is incorrect as decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 3 of 5
A 39 y.o. homemaker sees her physician after she falls twice for seemingly no reason. Diagnostic tests are done, and she is diagnosed with multiple sclerosis. Which of the ff. explanations will help her understand her disease?
Correct Answer: D
Rationale:
Step 1: Multiple sclerosis (MS) is characterized by damage to the myelin sheath, not a build-up of myelin.
Step 2: MS affects the nerves, not neurotransmitters related to muscle contraction (eliminates choice
B).
Step 3: MS does not damage receptor sites on muscles but affects nerve signal transmission (eliminates choice
C).
Step 4: The correct answer, D, explains that MS damages the insulation on nerve cells (myelin sheath), leading to slower nerve impulses to the muscles, causing weakness and coordination issues.
Question 4 of 5
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
Correct Answer: B
Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (
A) is not necessary as his burns are not infectious. Liberal visiting (
C) can increase the risk of infection and compromise his recovery. Sharing equipment (
D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.
Question 5 of 5
Which screening test for colorectal cancer should the nurse recommend?
Correct Answer: D
Rationale: The correct screening test for colorectal cancer is D: Proctosigmoidoscopy after age 50. This test allows direct visualization of the lower colon and rectum, aiding in the detection of polyps or tumors. It is recommended for individuals over 50 years old to screen for colorectal cancer. A: CEA test is not a primary screening tool but rather used for monitoring cancer progression. B: Annual digital examination is not sufficient for colorectal cancer screening. C: Barium enema is less effective compared to colonoscopy for detecting abnormalities in the colon.