ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Correct Answer: B
Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.
Question 2 of 9
Which of the ff is an important nursing intervention for HIV positive clients?
Correct Answer: D
Rationale: Step 1: Providing referral to support groups and resources for information is essential for HIV positive clients as it offers emotional support, education, and access to resources for managing the condition. Step 2: Support groups provide a safe space for clients to share experiences, seek advice, and reduce feelings of isolation. Step 3: Resources for information help clients stay informed about their condition, treatment options, and lifestyle modifications. Step 4: Referral to support groups and resources promotes holistic care and enhances the client's overall well-being. Summary: Choices A, B, and C are incorrect as they do not address the specific needs of HIV positive clients and may even pose risks to their health. Option D is the most appropriate intervention as it focuses on comprehensive support and empowerment for clients.
Question 3 of 9
In the nursing diagnosis 'Disturbed Self-Esteem related to presence of large scar over left side of face,' what part of the nursing diagnosis is 'presence of large scar over left side of face'?
Correct Answer: A
Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.
Question 4 of 9
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
Correct Answer: C
Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.
Question 5 of 9
In addition to antibiotics, which of the ff. recommendations can the nurse make to increase comfort in a patient experiencing sinusitis? Choose all answers that are correct. i. Coughing and deep breathing iv. Room humidifier ii. Sinus irrigation v. Percussion and postural drainage iii. Hot moist packs vi. Semi-fowler’s position
Correct Answer: D
Rationale: The correct answer is D: 2, 4, 5, and 6. 1. Room humidifier (choice 2) helps to keep the air moist, which can ease sinus pressure and discomfort. 2. Hot moist packs (choice 4) can provide relief by reducing congestion and promoting sinus drainage. 3. Percussion and postural drainage (choice 5) can help loosen mucus and improve drainage. 4. Semi-fowler's position (choice 6) can also aid in drainage and reduce sinus pressure. Choices A, B, and C are incorrect because they do not include all the recommended interventions that can help increase comfort in a patient with sinusitis. Each of the incorrect choices is missing at least one crucial recommendation that is beneficial for managing sinusitis symptoms.
Question 6 of 9
Which of the ff is the most important factor in the nursing management of clients who undergo treatment for a malignant tumor ff the urinary diversion procedure?
Correct Answer: C
Rationale: The correct answer is C: Observing for leakage of urine or stool from the anastomosis. This is crucial in nursing management post-urinary diversion procedure to prevent complications such as infection, dehydration, and skin breakdown. Leakage can indicate issues with the surgical site integrity and requires prompt intervention. A: Placement of IV and central venous pressure lines is important but not as critical as monitoring for leakage from the anastomosis. B: Administering cleansing enemas may be necessary for certain procedures but is not the most important factor in this case. D: Assessing the client's ability to manage self-catheterization is important for long-term care but does not take precedence over monitoring for potential complications like leakage. In summary, option C is the most important factor as it directly impacts the client's immediate post-operative care and helps prevent serious complications.
Question 7 of 9
A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which of the following glands?
Correct Answer: A
Rationale: The correct answer is A: Adrenal cortex. Primary hyperaldosteronism is a condition where the adrenal cortex produces too much aldosterone hormone, leading to hypertension. The adrenal medulla secretes adrenaline and noradrenaline, not aldosterone, making option B incorrect. The pancreas secretes insulin and glucagon, not aldosterone, making option C incorrect. Option D is incorrect because the adrenal cortex is responsible for aldosterone secretion in primary hyperaldosteronism.
Question 8 of 9
A female client recovers from a serious case of insect bites. What skin related advice must the nurse give to the client and all her family members to prevent the recurrence of the ailment?
Correct Answer: B
Rationale: The correct answer is B: Apply insect repellent to clothing and exposed skin. This advice helps prevent insect bites, reducing the risk of recurrence. Insect repellent creates a barrier against insects, hence minimizing the chances of getting bitten. Other choices are incorrect as they do not directly address the prevention of insect bites. Choice A is vague and does not provide a specific preventive measure. Choice C is incorrect as thick woollen clothing may not necessarily prevent insect bites. Choice D, sunscreen lotion, protects against UV rays, not insect bites.
Question 9 of 9
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because: A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression. C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding. D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.