ATI RN
Nursing Process Questions Questions
Question 1 of 5
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
Correct Answer: A
Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
Question 2 of 5
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
Correct Answer: B
Rationale: The correct answer is B: Profound neuromuscular irritability. In hypoparathyroidism, there is a decrease in parathyroid hormone leading to low calcium levels. This can result in neuromuscular irritability such as muscle cramps, spasms, and tingling. Monitoring for neuromuscular symptoms is crucial as they can progress to severe complications like seizures. Choices A, C, and D are incorrect because hypoparathyroidism does not typically present with severe hypotension, excessive thirst, or acute gastritis. Monitoring for signs of hypocalcemia and neuromuscular irritability is essential in managing hypoparathyroidism.
Question 3 of 5
The nurse caring for an adult client. The nurse will need to monitor for which of the following metabolic complications?
Correct Answer: C
Rationale: The correct answer is C, hyperglycemia and hypokalemia. Hyperglycemia can occur in adult clients due to various factors such as diabetes or stress. Hypokalemia can be a consequence of hyperglycemia or other conditions leading to potassium loss. Monitoring for these metabolic complications is essential to ensure the client's well-being. Other choices are incorrect because hypoglycemia and hypercalcemia (choice A) are less likely to occur concurrently in adult clients. Hyperglycemia and hyperkalemia (choice B) are less common as hyperkalemia is usually associated with renal dysfunction. Hyperkalemia and hypercalcemia (choice D) are less likely to be monitored together as they are not commonly seen in the same clinical context.
Question 4 of 5
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
Correct Answer: A
Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance. Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment. Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment. Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success. In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.
Question 5 of 5
A 25-year old with hepatitis may be anicteric and symptomless. In the early part of the hepatic inflammatory disorder, the most likely symptom/sign is:
Correct Answer: D
Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.
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