ATI RN
Nursing Process Questions Questions
Question 1 of 5
A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?
Correct Answer: A
Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet. Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.
Question 2 of 5
A client’s blood glucose levels remain elevated despite adherence to the prescribed treatment plan. What is the nurse’s best action?
Correct Answer: A
Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.
Question 3 of 5
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
Correct Answer: B
Rationale: The correct answer is B: Profound neuromuscular irritability. In hypoparathyroidism, there is a decrease in parathyroid hormone leading to low calcium levels. This can result in neuromuscular irritability such as muscle cramps, spasms, and tingling. Monitoring for neuromuscular symptoms is crucial as they can progress to severe complications like seizures. Choices A, C, and D are incorrect because hypoparathyroidism does not typically present with severe hypotension, excessive thirst, or acute gastritis. Monitoring for signs of hypocalcemia and neuromuscular irritability is essential in managing hypoparathyroidism.
Question 4 of 5
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
Correct Answer: B
Rationale: The correct answer is B: Bence jones protein in the urine. In multiple myeloma, abnormal plasma cells produce excess monoclonal immunoglobulins, including Bence Jones proteins, which can be detected in the urine. This is a hallmark finding in multiple myeloma diagnosis. A: Incorrect. Serum creatinine levels are typically not affected in multiple myeloma. C: Incorrect. Hypercalcemia, not hypocalcemia, is commonly seen in multiple myeloma due to bone destruction. D: Incorrect. Multiple myeloma often presents with high serum protein levels, not low levels.
Question 5 of 5
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
Correct Answer: A
Rationale: The correct answer is A: Age-related changes. Older clients are more susceptible to immune system disorders due to age-related changes such as a weakened immune response, increased inflammation, and decreased production of immune cells. Providing special care is important to address these specific vulnerabilities. Incorrect choices: B: Use of multiple drugs (Polypharmacy) - While polypharmacy can impact the immune system, it is not the primary factor for providing special care to older clients with immune system disorders. C: Poor diet - While diet plays a role in overall health, it is not the main factor necessitating special care for older clients with immune system disorders. D: Reduced activity levels - Although physical activity is important for overall health, reduced activity levels are not the primary reason for providing special care to older clients with immune system disorders.
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