ATI RN
Nursing Process Final Exam Questions Questions
Question 1 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 2 of 9
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
Correct Answer: C
Rationale: The correct answer is C: "It is a temporary interruption in the blood flow to the brain." This response is correct because it accurately describes a transient ischemic attack (TIA) as a temporary condition where blood flow to the brain is briefly interrupted. This explanation is clear, concise, and provides the family member with an accurate understanding of TIA. Choice A is incorrect because it deflects the question and suggests involving the doctor unnecessarily. Choice B is incorrect as it inaccurately states that TIA causes permanent brain damage, which is not true. Choice D is incorrect as it simply defines the acronym without providing any meaningful information about what TIA actually is.
Question 3 of 9
25-year old Francisco M., is diagnosed as having myelocytic leukemia and is admitted for chemotherapy. Francisco M.’s laboratory results indicate bone marrow depression. The nurse should encourage him to:
Correct Answer: B
Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because: A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression. C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding. D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.
Question 4 of 9
During a breast examination, which finding most strongly suggests that the client has breast cancer?
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.
Question 5 of 9
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?
Correct Answer: B
Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.
Question 6 of 9
A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
Correct Answer: C
Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition. Incorrect choices: A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it. B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed. D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.
Question 7 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.
Question 8 of 9
Which of the following would indicate that the patient has a normal corneal light reflex?
Correct Answer: D
Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.
Question 9 of 9
Which of the ff is an important nursing intervention for HIV positive clients?
Correct Answer: D
Rationale: Step 1: Providing referral to support groups and resources for information is essential for HIV positive clients as it offers emotional support, education, and access to resources for managing the condition. Step 2: Support groups provide a safe space for clients to share experiences, seek advice, and reduce feelings of isolation. Step 3: Resources for information help clients stay informed about their condition, treatment options, and lifestyle modifications. Step 4: Referral to support groups and resources promotes holistic care and enhances the client's overall well-being. Summary: Choices A, B, and C are incorrect as they do not address the specific needs of HIV positive clients and may even pose risks to their health. Option D is the most appropriate intervention as it focuses on comprehensive support and empowerment for clients.