Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Questions and Answers PDF Questions

Question 1 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, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because: A: Nurse's concerns are not the primary focus of a nursing health history. C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care. D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.

Question 2 of 5

Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:

Correct Answer: C

Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.

Question 3 of 5

Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?

Correct Answer: B

Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.

Question 4 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 5 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 care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs. A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations. C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences. D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.

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