ATI RN
Nursing Process Questions and Answers PDF Questions
Question 1 of 5
An adult has been treated for pulmonary tuberculosis and is being discharged home with his wife and two young children. His wife asks how TB is passed from one person to another so she can prevent anyone from catching it. How should the nurse respond?
Correct Answer: C
Rationale: Rationale: Step 1: Coughing is the primary way TB bacteria are spread. Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained. Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading. Step 4: This method reduces the risk of infecting family members. Summary of Incorrect Choices: A: Wearing gloves does not prevent airborne transmission of TB. B: Keeping windows closed can increase the concentration of bacteria in the air. D: Boiling water is not necessary to prevent TB transmission.
Question 2 of 5
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
Correct Answer: B
Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges. A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior. C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation. D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.
Question 3 of 5
Mr. Reyes has a possible skull fracture. The nurse should:
Correct Answer: A
Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.
Question 4 of 5
Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?
Correct Answer: C
Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning. Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation. Step 3: These help prevent pressure ulcers and maintain proper body alignment. Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care. Step 5: Footboard and splint may not be relevant to his specific condition. Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco. Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.
Question 5 of 5
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
Correct Answer: A
Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician. Rationale: 1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal. 2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache. 3. Following physician's direction is crucial to individualize care based on the specific situation. Summary of other choices: B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache. C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms. D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.