ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 9
A surgical intervention that can cause substantial remission of myasthenia gravis is:
Correct Answer: B
Rationale: The correct answer is B: Thymectomy. Thymectomy involves the surgical removal of the thymus gland, which is often abnormal in individuals with myasthenia gravis. The thymus plays a role in the development of the immune system and can contribute to the autoimmune response seen in myasthenia gravis. By removing the thymus gland, the autoimmune response may be reduced, leading to substantial remission of symptoms. Choice A, Esophagostomy, involves creating a surgical opening into the esophagus and is not a treatment for myasthenia gravis. Choice C, Myomectomy, is the surgical removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, Spleenectomy, is the removal of the spleen and is not a standard treatment for myasthenia gravis.
Question 2 of 9
The presence of anemia is characterized by a/an:
Correct Answer: C
Rationale: Step-by-step rationale: 1. Anemia is a condition where there is a decrease in the concentration of red blood cells. 2. Red blood cells carry oxygen to the body's tissues, so a decrease in their concentration leads to reduced oxygen delivery. 3. This decrease in red blood cell concentration can be measured through a decrease in hematocrit levels. 4. Choices A and B are incorrect because anemia involves a decrease, not an increase, in red blood cells and hemoglobin. 5. Choice D is incorrect as it mentions "decreased blood count cells," which is not a specific term related to anemia. Summary: The correct answer is C because anemia is characterized by a decrease in the concentration of red blood cells, leading to reduced oxygen delivery, while the other choices are incorrect due to inaccuracies in describing anemia.
Question 3 of 9
Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:
Correct Answer: C
Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.
Question 4 of 9
A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
Correct Answer: C
Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.
Question 5 of 9
Which food should be avoided by the patient on a low-sodium diet?
Correct Answer: C
Rationale: The correct answer is C: Cheese. Cheese is high in sodium and should be avoided on a low-sodium diet. Sodium can contribute to high blood pressure and other health issues. Apples, chicken, and broccoli are all low in sodium and can be included in a low-sodium diet. Cheese is the only option that is high in sodium, making it the correct choice to avoid.
Question 6 of 9
Why is heart biopsy performed throughout a clients lifetime after heart transplantation?
Correct Answer: A
Rationale: The correct answer is A: To detect rejection. After heart transplantation, heart biopsy is performed to monitor for rejection, a common complication. Tissue samples are examined for signs of rejection, such as inflammation. This is crucial for timely intervention to prevent rejection-related complications. Other choices are incorrect: B: Heart functionality is typically assessed through imaging tests like echocardiograms, not biopsy. C: Heart rate monitoring can be done through non-invasive methods like electrocardiograms, not biopsy. D: Checking for heart tumors is not a primary purpose of heart biopsy post-transplantation.
Question 7 of 9
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a cerebellar brain tumor can affect the client's coordination and balance due to its location in the brain responsible for fine motor movements. Impaired balance increases the risk for falls and injuries. Visual field deficits (choice A) may contribute to the risk of injury but not as directly as impaired balance. Difficulty swallowing (choice C) and psychomotor seizures (choice D) are not directly related to the client's risk for injury due to a cerebellar brain tumor.
Question 8 of 9
A client hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which of the following instructions would be most important to include in the client’s teaching plan?
Correct Answer: A
Rationale: The correct answer is A: maintain a moderate exercise. Exercise helps in maintaining bone density, which is crucial in managing hyperparathyroidism. Moderate exercise can also help in weight management and overall health. Choice B, losing weight, can be helpful but not as crucial as exercise. Choice C, jogging 2 miles per day, may be excessive for some individuals and not necessary for managing hyperparathyroidism. Choice D, resting as much as possible, is not recommended as it can lead to muscle weakness and bone loss, which are already concerns in hyperparathyroidism.
Question 9 of 9
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
Correct Answer: C
Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.