ATI RN
Fundamentals Nursing Process Questions Questions
Question 1 of 9
Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?
Correct Answer: D
Rationale: The correct answer is D: pain in the scapular region. This is because a herniated nucleus pulposus at the C4-C5 and C5-C6 interspaces typically results in pain radiating from the neck to the scapular region due to nerve compression at those levels. The other choices are incorrect as constant, throbbing headaches are not typically associated with this specific diagnosis, clonus in the lower extremities is more indicative of lower spinal cord involvement, and numbness of the face is not a common symptom of herniated discs at these levels.
Question 2 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 3 of 9
Which of the following is an early sign of anemia?
Correct Answer: B
Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.
Question 4 of 9
The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get with mammograms:
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. The American Cancer Society recommends yearly mammograms after age 40 for early breast cancer detection. 2. Mammograms are most effective for women aged 40 and older in detecting breast cancer. 3. Regular mammograms can help detect breast cancer at an early stage, improving treatment outcomes. Summary of why other choices are incorrect: B: Mammograms should start at age 40, not after the birth of the first child. C: Mammograms are not recommended after the first menstrual period; they should start at age 40. D: Mammograms should be done annually after age 40, not every 3 years between ages 20 and 40.
Question 5 of 9
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: Step 1: The scenario describes Toni minimizing her visual problems, planning advanced degrees, seeking full-time jobs, and wanting more children. Step 2: Choice B is correct because it recognizes Toni's behavior as a coping mechanism to deal with her illness. Step 3: Minimizing visual problems and focusing on future goals can be a way for Toni to maintain a positive outlook and cope with her challenges. Step 4: Choices A, C, and D are incorrect because they do not address Toni's behavior as a coping mechanism. Choice A mentions euphoria, which is not supported by the scenario. Choice C and D do not acknowledge Toni's coping mechanism but instead focus on different aspects like disease process and physical functioning.
Question 6 of 9
The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:
Correct Answer: B
Rationale: The correct answer is B: Pathologic bone fractures. In multiple myeloma, there is an increase in osteoclast activity leading to bone destruction, making patients prone to pathologic fractures. Chronic liver failure (A), acute heart failure (C), and hypoxemia (D) are not directly associated with multiple myeloma pathophysiology. This highlights the importance of understanding the disease process to determine the correct answer.
Question 7 of 9
Which of the following parts of neuron transmits impulses away from the cell body?
Correct Answer: C
Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals. Rationale: 1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect. 2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect. 3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.
Question 8 of 9
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
Correct Answer: D
Rationale: The correct answer is D: vasopressin (Pitressin). In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), which leads to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps regulate water balance by reducing urine output. Therefore, administering vasopressin would help manage the symptoms of diabetes insipidus. Insulin (A) is used for diabetes mellitus, not diabetes insipidus. Potassium chloride (B) is used to correct potassium imbalances, not specific to diabetes insipidus. Furosemide (Lasix) (C) is a diuretic that increases urine output, which would worsen the symptoms of diabetes insipidus.
Question 9 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 because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect as it assumes the patient's fear is related to dressing changes, not discharge. Choice B is incorrect as resuming medications is not linked to the patient's fear of being alone. Choice D is incorrect as there is no indication in the scenario that the surgery was unsuccessful.