ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 9
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
Question 2 of 9
A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Increased comfort. Radiation therapy for lung cancer aims to alleviate symptoms, reduce pain, and improve quality of life. It is not typically used as a curative treatment like surgery or chemotherapy (A). It does not prevent the need for oxygen (B), as lung cancer can still affect lung function. While radiation therapy may help control the growth of cancer cells, it is not always effective in preventing cancer spread (D). Therefore, the most appropriate expectation of radiation therapy for lung cancer is increased comfort for the patient.
Question 3 of 9
While managing a client after a medical or surgical procedure for bladder stones, for what rise in the temperature should the nurse notify the physician?
Correct Answer: C
Rationale: The correct answer is C: When the temperature rises above 102F. A temperature rise above 102F is concerning as it may indicate infection or other complications post-procedure. This higher threshold helps in early detection and timely intervention. Choices A and B set lower thresholds, potentially delaying necessary medical attention. Choice D is below the typical threshold for fever and would not typically warrant physician notification in this context.
Question 4 of 9
Which of the ff is an assessment finding in a client with bonchiectasis?
Correct Answer: D
Rationale: The correct answer is D. In bronchiectasis, worsening cough with position changes is an assessment finding due to increased sputum production and airway obstruction. This occurs because of the pooling of secretions in the affected bronchi. Choices A, B, and C are incorrect because in bronchiectasis, there is typically increased sputum production over time, productive cough with expectoration of large amounts of sputum, and cough that worsens with activity or physical exertion, rather than with position changes.
Question 5 of 9
Why should the nurse monitor angiotensin converting enzyme inhibitors cautiously in clients with renal or hepatic impairment and in older adults?
Correct Answer: B
Rationale: The correct answer is B: A sudden drop in BP may occur during the first 1-3 hours after the initial dose. Angiotensin converting enzyme inhibitors can cause vasodilation, leading to a reduction in blood pressure. In clients with renal or hepatic impairment and in older adults, these medications may not be cleared from the body as efficiently, increasing the risk of hypotension. Monitoring is crucial to prevent complications. Incorrect choices: A: A sudden raise in BP is unlikely with angiotensin converting enzyme inhibitors. C: Angiotensin converting enzyme inhibitors do not affect body temperature. D: Angiotensin converting enzyme inhibitors typically do not cause a sudden rise in pulse rate. In summary, monitoring for a potential drop in blood pressure is essential in vulnerable populations when using angiotensin converting enzyme inhibitors.
Question 6 of 9
A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he 'can’t live with this fear.' Which of the following diagnoses for this client is correctly written?
Correct Answer: A
Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. "Post-trauma syndrome" encompasses the psychological and emotional distress following a traumatic event. Choice B: Psychological overreaction simplifies the client's experience and does not capture the severity or ongoing nature of the trauma symptoms. Choice C: Needs assistance coping with attack is vague and does not provide a specific diagnosis or acknowledge the clinical presentation of the client. Choice D: Mental distress related to being attacked is too broad and does not specify the specific syndrome or symptoms experienced by the client.
Question 7 of 9
Cancer is the second major cause of death in this country. What is the first step toward effective cancer control?
Correct Answer: B
Rationale: The correct answer is B because changing habits and customs that predispose the individual to cancer is crucial in preventing cancer. This includes lifestyle changes such as quitting smoking, maintaining a healthy diet, exercising regularly, and avoiding excessive sun exposure. By modifying behaviors that increase cancer risk, individuals can significantly reduce their chances of developing cancer. A: Increasing governmental control of potential carcinogens is not the first step towards effective cancer control as individual behaviors have a more direct impact on cancer risk. C: Conducting more mass screening programs is important but not the first step as prevention through lifestyle changes takes priority. D: Educating the public and professionals about cancer is essential but changing habits is the initial crucial step in effective cancer control.
Question 8 of 9
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
Correct Answer: B
Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.
Question 9 of 9
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.