ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
Correct Answer: D
Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.
Question 2 of 5
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
Correct Answer: D
Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications. Summary: A: Lungs - Not directly affected by potassium levels. B: Liver - Not directly affected by potassium levels. C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.
Question 3 of 5
Which nursing diagnosis is most appropriate for a client with Addison’s disease?
Correct Answer: C
Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.
Question 4 of 5
Which of the ff is a sign or symptom of asthma?
Correct Answer: C
Rationale: The correct answer is C: Paroxysms or shortness of breath. Asthma is characterized by episodes of wheezing, coughing, chest tightness, and shortness of breath, known as paroxysms. This symptom is caused by inflammation and constriction of the airways in response to triggers such as allergens or irritants. A: Production of abnormally thick, sticky mucus in lungs is more indicative of conditions like cystic fibrosis, not asthma. B: Faulty transport of sodium in lung cells is associated with conditions like cystic fibrosis, not asthma. D: Altered electrolyte balance in the sweat glands is a symptom of cystic fibrosis, not asthma. In summary, paroxysms or shortness of breath is a key sign of asthma due to airway inflammation and constriction, distinguishing it from the other choices that are more indicative of cystic fibrosis.
Question 5 of 5
Which of the ff is a reason for providing early discharge instructions and making arrangements for home care for clients undergoing mastectomy?
Correct Answer: C
Rationale: Step 1: Most clients are not hospitalized long after a mastectomy - Correct. This is because mastectomy is often performed as an outpatient procedure, and clients are discharged home shortly after surgery. Step 2: The adverse effects of mastectomy are not immediate - Incorrect. Adverse effects may occur post-surgery, but early discharge is not solely due to immediate adverse effects. Step 3: The wound of the surgery is not highly contagious - Incorrect. Mastectomy wounds are not contagious, and isolation precautions are not necessary. Step 4: Suicidal tendencies in women undergoing mastectomy are not high - Incorrect. While emotional support is crucial, early discharge is not primarily due to suicidal tendencies. Summary: Choice C is correct because mastectomy clients are typically not hospitalized long, making early discharge instructions and home care arrangements necessary. Choices A, B, and D are incorrect as they do not directly relate to the primary reason for early discharge and home care planning.
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