ATI RN
Nursing Process Practice Questions Questions
Question 1 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.
Question 2 of 9
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.
Question 3 of 9
Which finding will alert the nurse that the goal has been met?
Correct Answer: A
Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.
Question 4 of 9
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life. Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.
Question 5 of 9
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
Correct Answer: A
Rationale: Correct Answer: A - Cerebral edema Rationale: 1. SIADH leads to water retention and dilutional hyponatremia. 2. Diuretic therapy aims to increase urine output and correct fluid imbalance. 3. If the client does not comply, excessive water retention can lead to cerebral edema. 4. Cerebral edema is a serious complication that can cause neurological deficits. Summary: - B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium. - C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss. - D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.
Question 6 of 9
During an ophthalmic assessment, which of the ff are the nurses expected to observe carefully? Choose all that apply
Correct Answer: B
Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health. A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment. C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses. D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.
Question 7 of 9
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
Correct Answer: A
Rationale: The correct answer is A: status of client’s tetanus immunization. It is critical because an open fracture poses a risk of infection, and tetanus prophylaxis is necessary to prevent tetanus infection. Tetanus is caused by a bacterium commonly found in soil and can enter the body through open wounds. Assessing the client's tetanus immunization status helps determine the need for a tetanus booster to prevent potential complications. Incorrect choices: B: Current blood alcohol level - While relevant to the situation, the priority in this case is preventing infection from the open fracture. C: Support systems available at home to assist with care - Important for discharge planning but not the immediate priority. D: Last time client voided - Not critical in this scenario compared to preventing infection from the open fracture.
Question 8 of 9
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
Correct Answer: A
Rationale: The correct answer is A: Provide positive feedback when he uses the word correctly. In individuals with expressive aphasia, positive reinforcement helps improve communication skills. Praising Mr. Reyea when he uses words correctly encourages continued effort and boosts confidence. This approach motivates him to communicate more despite his challenges. Summary of other choices: B: Waiting indefinitely for Mr. Reyea to verbally state needs is not practical and may lead to frustration. C: Suggesting permanent help at home assumes the disability cannot improve, which is not necessarily true for expressive aphasia. D: Helping the family to accept Mr. Reyea's inability to communicate verbally may hinder his progress and limit his social interactions.
Question 9 of 9
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
Correct Answer: C
Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.