ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
Correct Answer: A
Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician. Rationale: 1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal. 2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache. 3. Following physician's direction is crucial to individualize care based on the specific situation. Summary of other choices: B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache. C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms. D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.
Question 2 of 5
Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:
Correct Answer: C
Rationale: The correct answer is C because it addresses the specific nursing intervention needed to prepare Mr. RR for the brain scanning test. By explaining to Mr. RR that the test will not be painful and that his head will be supported in place, the nurse helps alleviate any potential anxiety or fear he may have. This information reassures the patient and ensures his cooperation during the procedure. Choice A is incorrect because discontinuing anticonvulsant therapy without medical approval could have serious consequences for Mr. RR's health. Choice B is also incorrect as obtaining consent is important, but it is not directly related to preparing Mr. RR for the test. Choice D is incorrect as it introduces potential negative outcomes without providing necessary information to prepare the patient for the test.
Question 3 of 5
When testing visual fields, the nurse is assessing which of the following parts of vision?
Correct Answer: A
Rationale: The correct answer is A: Peripheral vision. When testing visual fields, the nurse evaluates the ability to see objects outside the direct line of sight, which is indicative of peripheral vision. Peripheral vision helps detect objects and movement in the side vision. Distance vision (B) refers to the ability to see clearly at a distance, while near vision (C) pertains to close-up vision. Central vision (D) is essential for focusing on details and seeing straight ahead. Therefore, A is the correct choice as it specifically pertains to the assessment of visual fields.
Question 4 of 5
The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
Correct Answer: A
Rationale: The correct answer is A: Antihistamines. Labyrinthitis is an inner ear condition often caused by inflammation or infection. Antihistamines help reduce symptoms like vertigo and dizziness by decreasing inflammation and fluid buildup in the inner ear. Anti-inflammatories (choice B) may help with inflammation but are not as effective for inner ear conditions. Antispasmotics (choice C) are not typically used for treating labyrinthitis. Antiemetics (choice D) are used to control nausea and vomiting, which can be symptoms of labyrinthitis but do not address the underlying cause.
Question 5 of 5
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She’s fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for this client is C: Deficient fluid volume related to osmotic diuresis induced by hypernatremia. The client's elevated sodium level of 152mEq/L indicates hypernatremia, which leads to osmotic diuresis and subsequent fluid loss. This results in deficient fluid volume, causing the client to urinate frequently and experience fatigue from lack of sleep. The other choices are incorrect because: A: Deficient fluid volume related to inability to conserve water is not the most appropriate diagnosis as the primary issue is the osmotic diuresis induced by hypernatremia, not the client's inability to conserve water. B: Imbalanced nutrition: Less than body requirements related to hypermetabolic state is not the most appropriate diagnosis as the client's weight loss is likely due to fluid loss from osmotic diuresis, not a hypermetabolic state. D: Imbalanced nutrition: Less than body requirements related to catab