ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?
Correct Answer: C
Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood. Incorrect choices: A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia. B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia. D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.
Question 2 of 5
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints. Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions. Step 3: This promotes circulation and reduces pressure on bony prominences. Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.
Question 3 of 5
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
Question 4 of 5
Which type of neuron transmits impulses from the central nervous system to the muscles and glands?
Correct Answer: C
Rationale: The correct answer is C: Efferent neurons transmit impulses from the central nervous system to muscles and glands. This is because efferent neurons are responsible for carrying motor signals away from the central nervous system to control muscle movement and gland secretion. Afferent neurons (choice A) transmit sensory information from the body to the central nervous system. Affective (choice B) is not a term used in neuroscience for describing neuron functions. Effective (choice D) is not a term used in neuroscience and does not describe the specific function of transmitting impulses from the central nervous system to muscles and glands.
Question 5 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.