ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?
Correct Answer: B
Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.
Question 2 of 5
Which of the following nursing activities is an example of evaluation?
Correct Answer: A
Rationale: The correct answer is A because checking a client's blood pressure after administering medication assesses the effectiveness of the intervention. Evaluation involves determining if the desired outcomes were achieved. Administering oxygen therapy (B) is an implementation task. Developing a plan of care (C) is part of the assessment and planning phase. Teaching about dietary options (D) is part of the implementation phase. In conclusion, only option A involves assessing the outcome of an intervention, making it the correct choice for evaluation.
Question 3 of 5
While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?
Correct Answer: A
Rationale: Step 1: Involving the client in planning increases their understanding and ownership of the plan. Step 2: Understanding leads to better compliance with therapy recommendations. Step 3: Compliance improves outcomes and prevents complications. Step 4: Thus, choice A is correct. Choices B, C, and D lack direct links to client involvement in planning and compliance.
Question 4 of 5
A college student goes to the college clinic and asks the best way to avoid contracting an STD. The nurse provides the clinic’s standard STD teaching. Which statement by the student indicates the need for additional instruction?
Correct Answer: D
Rationale: The correct answer is D. This statement indicates a need for additional instruction because questioning a partner about past sexual encounters may not be a reliable method to avoid STDs. Here's the rationale: 1. A: Correct - Acknowledges the reality that engaging in sexual activity carries risks, even with precautions. 2. B: Correct - Emphasizes that abstinence is the most effective way to prevent STD transmission. 3. C: Correct - Using a condom with spermicide can reduce the risk of STD transmission, although it's not foolproof. 4. D: Incorrect - Relying solely on partner questioning is not a comprehensive or foolproof method to prevent STDs. It overlooks the potential for misinformation or lack of disclosure from the partner.
Question 5 of 5
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
Correct Answer: B
Rationale: The correct answer is B: 2.0mEq/L. Severe vomiting can lead to hypokalemia, characterized by flat T waves and ST segment depression on ECG. This is due to decreased potassium levels affecting cardiac repolarization. A potassium level of 2.0mEq/L is dangerously low and consistent with the ECG findings in this scenario. Choices A, C, and D have potassium levels that are not reflective of severe hypokalemia, therefore they are incorrect. Option A (4.0mEq/L) is within the normal range, option C (8.0mEq/L) is elevated, and option D (2.6mEq/L) is higher than the correct value of 2.0mEq/L.