ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
A patient with a history of haemophilia A arrives in the emergency department complaining of a “funny feeling” in his elbow. The patient states that he thinks he is bleeding into the joint. Which response by the nurse is correct?
Correct Answer: B
Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention. Choices A, C, and D are incorrect: A: Palpating the elbow could exacerbate the bleeding and cause further damage. C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding. D: Applying heat can increase blood flow to the joint, worsening the bleeding.
Question 2 of 9
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?
Correct Answer: B
Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.
Question 3 of 9
The nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?
Correct Answer: D
Rationale: Step 1: Levothyroxine (Synthroid) is the synthetic form of the thyroid hormone T4, the main hormone produced by the thyroid gland. Step 2: Levothyroxine is the preferred agent for thyroid hormone replacement therapy in hypothyroidism due to its stable and consistent potency. Step 3: Levothyroxine is well-absorbed by the body and has a long half-life, allowing for once-daily dosing. Step 4: Other choices are incorrect because Methimazole is used to treat hyperthyroidism, Livothyronine is a form of T3 hormone not commonly used for replacement therapy, and Thyroid USP dessicated is derived from animal thyroid glands and has inconsistent hormone content. Summary: Levothyroxine (Synthroid) is the preferred choice for thyroid hormone replacement therapy due to its synthetic nature, stable potency, good absorption, and long half-life. Other options are not
Question 4 of 9
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?
Correct Answer: A
Rationale: The correct answer is A: The client’s airway should be assessed first. This is because airway management is the top priority in any emergency situation to ensure the patient can breathe. Without a patent airway, the patient's oxygenation and ventilation will be compromised, leading to serious complications or death. Choices B, C, and D are incorrect because assessing the airway takes precedence over determining the reason for admission, reviewing medications, or assessing past medical history in an unconscious patient. These other assessments are important but not as critical as securing the airway to maintain the patient's breathing and oxygenation.
Question 5 of 9
Which of the ff finding would confirm that a female client has mastitis? Choose all that apply
Correct Answer: C
Rationale: The correct answer is C because mastitis typically presents with swollen, firm, and hard breasts due to inflammation and infection of the breast tissue. This occurs as a result of milk stasis and bacterial infection. Option A is incorrect because a crack in the nipple or areola can be indicative of nipple trauma or infection, not necessarily mastitis. Option B is incorrect because multiple lumps within the breast tissue may suggest fibrocystic changes or breast cancer, but not specifically mastitis. Option D is incorrect because enlargement of the axillary lymph nodes is more commonly seen in breast cancer, not mastitis.
Question 6 of 9
What should a male client over age 50 do to help ensure early identification of prostate cancer?
Correct Answer: A
Rationale: Rationale: 1. Digital rectal exam (DRE) and PSA test are recommended by major health organizations for prostate cancer screening in men over 50. 2. DRE helps detect abnormalities in the prostate, while PSA test measures the levels of a protein produced by the prostate gland. 3. Prostate cancer can be asymptomatic in its early stages, so regular screening is crucial for early detection and treatment. 4. Transrectal ultrasound is not a primary screening method for prostate cancer. 5. Testicular self-exams are for detecting testicular cancer, not prostate cancer. 6. CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.
Question 7 of 9
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
Correct Answer: B
Rationale: The correct answer is B: Wear sunglasses. Dilated pupils are sensitive to light, so wearing sunglasses can help protect the eyes from excessive light exposure. Keeping the eyes closed (A) may provide temporary relief but does not protect the eyes from light. Avoiding driving for 8 hours (C) is important after certain eye procedures but not specifically related to dilated pupils. Avoiding caffeinated beverages (D) is unrelated to pupil dilation.
Question 8 of 9
A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.
Question 9 of 9
At a public health fair, a nurse discusses the dangers of sun exposure. Prolonged sun exposure has been blamed for which form of cancer?
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Malignant melanoma, basal cell epithelioma, and squamous cell carcinoma are all types of skin cancer associated with prolonged sun exposure. Melanoma is the most dangerous form, while basal cell and squamous cell carcinomas are more common but less aggressive. Sun exposure can lead to DNA damage in skin cells, increasing the risk of developing these types of cancers. Therefore, all three choices are correct as they are all linked to sun exposure. The other choices are incorrect because each type of skin cancer mentioned can be caused by prolonged sun exposure, so selecting any one of them individually would not fully capture the scope of the risks associated with sun exposure.