ATI RN
Nursing Process NCLEX Questions Questions
Question 1 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 2 of 5
. A female client experiences trauma to her urinary tract during an accident. Which of the ff factors should the nurse consider while assessing the client?
Correct Answer: B
Rationale: The correct answer is B: Assessment and recognition of abnormal findings. This is crucial as trauma to the urinary tract can lead to various complications such as urinary retention, infection, or injury to surrounding structures. By assessing and recognizing abnormal findings, the nurse can promptly identify any issues and initiate appropriate interventions.
Choice A (Assessment of sexual habits) may be important for assessing risk factors for urinary tract trauma, but it is not directly related to assessing the client's current condition post-accident.
Choice C (Assessment of allergies to seafood) is irrelevant in this scenario as it does not impact the assessment of urinary tract trauma.
Choice D (Assessment of insurance coverage) is not a priority when assessing a client's immediate health status post-accident.
Question 3 of 5
Which of the ff conditions is evident by persistent hoarseness?
Correct Answer: C
Rationale: The correct answer is C: Laryngeal cancer. Persistent hoarseness is a common symptom of laryngeal cancer due to vocal cord involvement. Laryngeal cancer causes changes in voice quality over time. Bacterial infection (
A) usually presents with acute symptoms and resolves with treatment. Aphonia (
B) is the complete loss of voice, not persistent hoarseness. Peritonsillar abscess (
D) causes sore throat and difficulty swallowing, but not persistent hoarseness.
Question 4 of 5
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully.
Choice B may overwhelm the patient,
Choice C disrupts the communication process, and
Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
Question 5 of 5
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A because completing a comprehensive database is part of the first phase of the nursing process, which is assessment. During assessment, the nurse gathers data about the patient's health status. This information is crucial for identifying health problems, developing nursing diagnoses, planning interventions, and evaluating outcomes.
Choice B is incorrect because identifying nursing diagnoses is part of the second phase, which is diagnosis.
Choice C is incorrect as intervening based on priorities of patient care is part of the third phase, which is planning.
Choice D is incorrect because determining whether outcomes have been achieved is part of the fourth phase, which is evaluation.