ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.
Question 2 of 5
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome. Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success. Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step. Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.
Question 3 of 5
A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?
Correct Answer: D
Rationale: The correct answer is D: Peritonitis. Peritonitis is a major complication of peritoneal dialysis due to infection of the peritoneum. It can lead to serious consequences if not treated promptly. The nurse should monitor for signs of peritonitis such as abdominal pain, cloudy dialysate, fever, and increased white blood cell count. Internal hemorrhage (A), hydronephrosis (B), and ecchymosis (C) are not major complications specific to peritoneal dialysis. Internal hemorrhage can occur but is less common. Hydronephrosis is more related to obstruction of the ureters. Ecchymosis refers to bruising and is not directly associated with peritoneal dialysis.
Question 4 of 5
A 23 y.o. woman is seen at an outpatient clinic for a routine Pap smear. When questioned, she states she is deciding whether to engage in sexual activity with a man she is just getting to know. She asks how she can tell if he has an STD. Which response by the nurse is best?
Correct Answer: D
Rationale: Step 1: The correct answer is D because it emphasizes the importance of medical examination and diagnostic testing to determine if the man has an STD. Step 2: Visual inspection (choice B) is not reliable as some STDs may not present with visible symptoms. Step 3: Relying solely on appearance and condom use (choices A and C) does not guarantee protection against all STDs. Step 4: Choice D is the best option as it advocates for seeking professional medical advice for accurate diagnosis and treatment.
Question 5 of 5
One of the dangers of treating hypernatremia is:
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications. Incorrect choices: A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia. C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis. D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.