ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
Question 2 of 9
The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
Correct Answer: B
Rationale: The correct answer is B: The waiting area with the television turned off. This choice eliminates potential distractions, allowing the patient with a hearing deficit to focus on the interview. Noise from the television can interfere with communication. Other choices are incorrect because: A) The closed door may block out external noise, but the patient's room could still have distractions. C) Administering pain medication can affect the patient's alertness and ability to communicate effectively. D) The waiting room with occupational therapy activities can be noisy and distracting. Conducting the interview in a quiet waiting area ensures optimal communication and understanding.
Question 3 of 9
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.
Question 4 of 9
An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?
Correct Answer: C
Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.
Question 5 of 9
Which client has the highest risk of ovarian cancer?
Correct Answer: B
Rationale: The correct answer is B: 45-year old woman who has never been pregnant. The risk of ovarian cancer increases with age and nulliparity (never having been pregnant) is a significant risk factor. The older a woman gets without having been pregnant, the higher her risk of developing ovarian cancer. The other choices do not have as high of a risk factor for ovarian cancer. Choice A, a 30-year old woman taking contraceptives, actually reduces the risk of ovarian cancer. Choice C, a 40-year old woman with three children, and choice D, a 36-year old woman who had her first child at age 22, both have lower risk factors compared to choice B.
Question 6 of 9
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.
Question 7 of 9
Management of the foregoing patient should include:
Correct Answer: D
Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.
Question 8 of 9
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
Correct Answer: B
Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.
Question 9 of 9
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
Correct Answer: A
Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition. Summary of why the other choices are incorrect: B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia. C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia. D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.