ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
A 45-year-old patient has a long- standing history of allergies to pollen. Which of the following actions indicates that the patient does not understand how to control this disease?
Correct Answer: C
Rationale: The correct answer is C. Driving in the car with the windows open exposes the patient to pollen, worsening allergies. Staying indoors on dry, windy days (A) reduces exposure. Refusing to walk outside in spring (B) also minimizes exposure. Working in the garden on sunny days (D) increases pollen exposure. Therefore, choice C is the only action that goes against controlling pollen allergies.
Question 2 of 5
Which immunoglobulin is specific to an allergic response?
Correct Answer: B
Rationale: The correct answer is B: IgE. IgE is specific to allergic responses as it binds to mast cells and basophils, triggering the release of histamine and other inflammatory mediators. IgA is more involved in mucosal immunity, IgG is involved in long-term immunity and opsonization, and IgM is the primary antibody in the primary immune response. IgB is not a known immunoglobulin. Therefore, IgE is the specific immunoglobulin associated with allergic responses due to its role in mediating hypersensitivity reactions.
Question 3 of 5
The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?
Correct Answer: B
Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.
Question 4 of 5
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
Correct Answer: D
Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.
Question 5 of 5
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Correct Answer: C
Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.