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
The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?
Correct Answer: C
Rationale: The correct answer is C: Normal saline solution. Phenytoin is incompatible with dextrose solutions, so options A and D are incorrect. Lactated Ringer's solution contains calcium, which can interact with phenytoin, leading to precipitation. Therefore, option B is also incorrect. Normal saline is the most compatible diluent for phenytoin, maintaining the drug's stability and effectiveness. It is essential to use the appropriate diluent to prevent adverse reactions or drug interactions.
Question 3 of 5
Which of the following terms indicates that the patient has a hearing loss caused by aging?
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
Question 4 of 5
Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
Correct Answer: C
Rationale: The correct answer is C: Halos around lights. This symptom is specific to acute angle-closure glaucoma due to increased intraocular pressure causing corneal edema. Halos around lights are caused by light diffraction through edematous cornea. Flashing lights and lens opacity are not typically associated with acute angle-closure glaucoma. Flashing lights may be seen in retinal detachment, while lens opacity is more commonly seen in cataracts.
Question 5 of 5
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal