ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
Correct Answer: D
Rationale: The correct answer is D:
To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay.
Explanation of other options:
A:
To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database.
B:
To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems.
C:
To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose
Question 2 of 5
The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?
Correct Answer: B
Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation.
Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment.
Choice C is too vague, as it does not specify the exact response of the pupils.
Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation.
Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.
Question 3 of 5
During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:
Correct Answer: C
Rationale: Rationale for
Choice C (Correct Answer):
1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm.
2. MS is characterized by demyelination of nerves, leading to visual disturbances.
3. Optic nerve involvement results in vision problems, such as blurred vision.
4. Chiasm involvement can cause visual field deficits and color perception changes.
Summary of Other
Choices:
A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles.
B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS.
D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.
Question 4 of 5
Wilma knew that the maximum time when suctioning James is
Correct Answer: C
Rationale: The correct answer is C (30 seconds) because the maximum recommended time for suctioning a patient is typically around 10-15 seconds for each pass. Prolonged suctioning can lead to tissue damage, hypoxia, and increased risk of infection. In this case, given the patient's symptoms and medical history (vomiting, weight loss, dehydration, hypotension), it is crucial to limit suction time to prevent further complications.
Choices A, B, and D are incorrect as they exceed the safe duration for suctioning and increase the risk of harm to the patient.
Choice D, in particular, is significantly longer than the recommended time and could pose serious risks to the patient's health in this situation.
Question 5 of 5
A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
Correct Answer: D
Rationale:
Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.