ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 5
A client with thrombocytopenia secondary to leukemia develops epistaxis. The nurse should instruct the client to:
Correct Answer: B
Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.
Question 2 of 5
The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:
Correct Answer: D
Rationale: The correct answer is D, decreased body temperature and cold intolerance, because these are classic signs of hypothyroidism due to decreased thyroid hormone levels. The body's metabolism slows down, leading to a lower core body temperature and reduced ability to tolerate cold. Exophthalmos and conjunctival redness (choice A) are associated with hyperthyroidism. Flushed, warm, moist skin (choice B) is indicative of hyperthyroidism as well, due to increased metabolic rate. A systolic murmur at the left sternal border (choice C) is not a common finding in hypothyroidism.
Question 3 of 5
The presence of anemia is characterized by a/an:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anemia is a condition where there is a decrease in the concentration of red blood cells. 2. Red blood cells carry oxygen to the body's tissues, so a decrease in their concentration leads to reduced oxygen delivery. 3. This decrease in red blood cell concentration can be measured through a decrease in hematocrit levels. 4. Choices A and B are incorrect because anemia involves a decrease, not an increase, in red blood cells and hemoglobin. 5. Choice D is incorrect as it mentions "decreased blood count cells," which is not a specific term related to anemia. Summary: The correct answer is C because anemia is characterized by a decrease in the concentration of red blood cells, leading to reduced oxygen delivery, while the other choices are incorrect due to inaccuracies in describing anemia.
Question 4 of 5
Before administering a food feeding the nurse knows to perform which of the following assessments/
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
Question 5 of 5
Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?
Correct Answer: D
Rationale: The correct answer is D: pain in the scapular region. This is because a herniated nucleus pulposus at the C4-C5 and C5-C6 interspaces typically results in pain radiating from the neck to the scapular region due to nerve compression at those levels. The other choices are incorrect as constant, throbbing headaches are not typically associated with this specific diagnosis, clonus in the lower extremities is more indicative of lower spinal cord involvement, and numbness of the face is not a common symptom of herniated discs at these levels.
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