ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
Correct Answer: A
Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.
Question 2 of 5
A nurse is conducting a nursing health history. Which component will the nurse address?
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for their health care. By focusing on the patient's expectations, the nurse can establish a therapeutic relationship, provide patient-centered care, and tailor the care plan accordingly. A: Nurse's concerns - Incorrect. The nursing health history should prioritize the patient's perspective and needs over the nurse's concerns. C: Current treatment orders - Incorrect. While important, this component focuses on the medical treatment plan rather than the patient's expectations. D: Nurse's goals for the patient - Incorrect. The nurse should collaborate with the patient to set goals that align with the patient's needs and preferences, not impose their own goals.
Question 3 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 4 of 5
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process. B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully. C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood. D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
Question 5 of 5
Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.
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