ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
Correct Answer: C
Rationale: Rationale for Correct Answer (C): 1. Paraplegia is a condition where both lower extremities are paralyzed. 2. The prefix "para-" means alongside or beside, indicating that both legs are affected. 3. The nurse would explain to the family that Mr. Gubatan has paralysis in his lower extremities only. 4. This aligns with the medical definition of paraplegia. Summary of Incorrect Choices: A. Upper extremities being paralyzed is not indicative of paraplegia, as paraplegia specifically refers to lower extremity paralysis. B. Both lower and upper extremities being paralyzed is suggestive of quadriplegia, not paraplegia. D. One side of the body being paralyzed describes hemiplegia, not paraplegia.
Question 2 of 5
Usually, how does the patient behave after his seizure has subsided?
Correct Answer: B
Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.
Question 3 of 5
Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?
Correct Answer: C
Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions. A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome. B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome. D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.
Question 4 of 5
Which of the ff instructions should be given to the clients family if a client with impaired swallowing has to take solid medication?
Correct Answer: C
Rationale: The correct answer is C because crushing or breaking tablets can alter the medication's effectiveness or cause harm. Step 1: Consult a physician or pharmacist ensures safety and effectiveness. Step 2: This step helps in determining if the medication can be safely altered for easier swallowing. Step 3: Using liquid form (B) may not always be an option. Mixing with food (A) can affect absorption. ROM exercises (D) are unrelated to medication administration.
Question 5 of 5
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.