ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.
Question 2 of 5
A nurse is working with a dying client and his family. Which communication technique is most important to use?
Correct Answer: D
Rationale: The correct answer is D: Active listening. Active listening involves fully concentrating, understanding, responding, and remembering what is being said. In end-of-life care, it is crucial to provide emotional support and create a safe space for clients and their families to express their thoughts and feelings. Active listening helps the nurse to establish trust, show empathy, and validate the emotions of the clients and their families. Reflection (A), Clarification (B), and Interpretation (C) may be beneficial in certain situations, but in end-of-life care, active listening plays a pivotal role in fostering meaningful and supportive communication.
Question 3 of 5
While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
Correct Answer: B
Rationale: The correct answer is B: Eat a diet high in protein and calories to optimize tissue repair. Rationale: 1. Protein is essential for tissue repair and healing, which can help counteract the effects of radiation therapy on the skin and swallowing function. 2. Calories are necessary for energy to support the body's healing processes during radiation therapy. 3. A diet high in protein and calories can help maintain overall nutritional status and promote recovery. Incorrect Choices: A: Washing the radiation site vigorously can further irritate the skin, leading to more complications. C: Cool compresses may not be suitable for radiation-induced skin reactions and may not address the underlying issue of dysphagia. D: Drinking warm fluids may not directly address the need for optimal tissue repair and healing.
Question 4 of 5
Which of the ff nursing interventions would a nurse perform to avoid maceration from irritating drainage or the wound compresses in a client with breast abscess?
Correct Answer: A
Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration. Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.
Question 5 of 5
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
Correct Answer: B
Rationale: The correct answer is B: Pink, frothy sputum. This is because pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. Furosemide IV is a diuretic that helps remove excess fluid from the body, including the lungs. Resolving pink, frothy sputum indicates that the treatment is effectively reducing the fluid in the lungs. Incorrect choices: A: Pedal edema - This refers to swelling in the feet and ankles, which is not directly related to pulmonary edema. C: Jugular vein distention - This is a sign of heart failure, not specifically pulmonary edema. D: Bradycardia - This is a slow heart rate and not a direct indicator of pulmonary edema resolution.