ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
Correct Answer: C
Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients. Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf. Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image. Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery. In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.
Question 2 of 5
Which of the following best defines the process of evaluating a nursing intervention?
Correct Answer: A
Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes. Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.
Question 3 of 5
A client has been diagnosed with renal failure and is admitted for dialysis. Which of the ff is the nurse’s responsibility as the client undergone dialysis?
Correct Answer: C
Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.
Question 4 of 5
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
Correct Answer: B
Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.
Question 5 of 5
A patient complains of tingling in his fingers. He has positive Trousseau’s and Chvostek’s signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
Correct Answer: A
Rationale: The correct answer is A: 11mg/dl. This patient is likely experiencing hypocalcemia, indicated by positive Trousseau's and Chvostek's signs. These signs suggest neuromuscular irritability due to low calcium levels. A serum calcium level of 11mg/dl is higher than normal, indicating possible hyperparathyroidism causing high calcium levels. Choices B, C, and D are lower than normal, which would exacerbate symptoms rather than alleviate them.