ATI RN
Nursing Process Test Bank Questions
Question 1 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.
Question 2 of 5
When can a donor and recipient of blood be considered compatible?
Correct Answer: C
Rationale: The correct answer is C because compatibility between blood donor and recipient is determined by the absence of clumping or hemolysis when both samples are mixed. Clumping indicates an incompatible blood type reaction, leading to potential harm. Blood clots (option B) are not indicative of compatibility but rather a sign of coagulation issues. Blood color change (option A) and blood drop sinking in water (option D) are not reliable indicators of blood compatibility. In summary, option C is correct as it directly assesses for the absence of a harmful reaction, while the other choices do not accurately determine blood compatibility.
Question 3 of 5
What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
Correct Answer: C
Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections. Now, let's analyze the other choices: A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy. B: Sleep in a semi-fowler’s position - Positioning does not directly impact infection prevention post-splenectomy. D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.
Question 4 of 5
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
Correct Answer: A
Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition. Summary of why the other choices are incorrect: B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia. C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia. D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.
Question 5 of 5
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
Correct Answer: B
Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.