ATI RN
Nursing Process Questions Questions
Question 1 of 9
A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?
Correct Answer: D
Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition. A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain. B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer. C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.
Question 2 of 9
Which patient should be monitored most closely for dehydration?
Correct Answer: A
Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.
Question 3 of 9
The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy. Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS. Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent. Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.
Question 4 of 9
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This is the most appropriate nursing diagnosis for a patient with pneumonia and lower lobe infiltrates. The rationale is that pneumonia causes inflammation and fluid accumulation in the alveoli, impairing the exchange of oxygen and carbon dioxide in the lungs. This directly affects gas exchange. Choice A is incorrect because ineffective breathing pattern is a broad nursing diagnosis that does not specifically address the underlying issue of impaired gas exchange in pneumonia. Choice B is incorrect as the risk of infection related to the chest x-ray procedure is unrelated to the patient's current condition of pneumonia. Choice C is also incorrect as dehydration does not directly correlate with the patient's diagnosis of pneumonia and lower lobe infiltrates.
Question 5 of 9
A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. Myocardial infarction, hypertension, and progressive systemic sclerosis can lead to impaired circulation and skin breakdown. Clients with these conditions are at risk for pressure ulcers due to decreased blood flow and compromised skin integrity. The other options, B: Imbalanced nutrition, C: Constipation, and D: Ineffective thermoregulation, do not directly relate to the client's conditions or the potential complications associated with them. Therefore, the most appropriate nursing diagnosis for this client would be A: Risk for impaired skin integrity.
Question 6 of 9
Which of the following conditions is suspected?
Correct Answer: A
Rationale: The correct answer is A: Anemia. Anemia is a common condition characterized by a decrease in red blood cells or hemoglobin levels, leading to symptoms like fatigue and weakness. It is often suspected based on symptoms such as pale skin and shortness of breath. Rheumatic arthritis (B) is a type of arthritis affecting joints, not related to the blood. Leukemia (C) is a type of cancer affecting the blood and bone marrow. Systemic Lupus Erythematosus (SLE) (D) is an autoimmune disease that can affect various organs, not specifically related to blood cell levels. Therefore, based on the symptoms described, anemia is the most likely condition to be suspected.
Question 7 of 9
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 8 of 9
When a neurologist asks a patient to smile, which cranial nerve is being tested?
Correct Answer: C
Rationale: Step-by-step rationale: 1. The cranial nerve responsible for facial expression is CN VII, the facial nerve. 2. When a neurologist asks a patient to smile, they are testing the function of CN VII. 3. CN II (optic nerve) is responsible for vision, not facial expression. 4. CN X (vagus nerve) is responsible for various functions like heart rate and digestion, not facial expression. 5. CN XI (accessory nerve) is responsible for shoulder movement, not facial expression. Summary: Testing a patient's ability to smile involves assessing the function of CN VII, the facial nerve. Choices A, B, and D are incorrect as they are associated with different functions and not responsible for controlling facial muscles.
Question 9 of 9
If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
Correct Answer: B
Rationale: The correct answer is B because right-sided weakness is typically associated with damage or impairment in the left lobe of the brain. The brain controls the opposite side of the body, so weakness on the right side indicates left brain involvement. This is known as contralateral control. The other choices are incorrect because expressive aphasia is associated with left brain damage, problems in judging distance and proprioception are related to parietal lobe damage, and orientation to time and space is more related to frontal lobe damage. Therefore, the most accurate analysis by the nurse would be to consider the affected lobe as the right lobe in this case.