ATI RN
Nursing Process Questions Questions
Question 1 of 5
The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?
Correct Answer: C
Rationale: The correct answer is C because in myasthenia gravis, which is characterized by muscle weakness and fatigue, the administration of edrophonium will temporarily improve muscle strength due to increased availability of acetylcholine at the neuromuscular junction. This improvement should be noted within 30 to 60 seconds after the administration of the medication. Choice A is incorrect because joint pain is not a typical response to edrophonium in the context of myasthenia gravis. Choice B is incorrect because feelings of faintness, dizziness, hypotension, and flushing are more indicative of a cholinergic crisis, which occurs when too much edrophonium is administered. Choice D is incorrect because an increase in muscle strength post-edrophonium administration would not be expected in a client with myasthenia gravis.
Question 2 of 5
A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity. Myocardial infarction, hypertension, and progressive systemic sclerosis can lead to impaired circulation and skin breakdown. Clients with these conditions are at risk for pressure ulcers due to decreased blood flow and compromised skin integrity. The other options, B: Imbalanced nutrition, C: Constipation, and D: Ineffective thermoregulation, do not directly relate to the client's conditions or the potential complications associated with them. Therefore, the most appropriate nursing diagnosis for this client would be A: Risk for impaired skin integrity.
Question 3 of 5
Which of the following explanations by the nurse will help a patient understand what to expect during a bronchoscopy?
Correct Answer: A
Rationale: The correct answer is A because it accurately describes the procedure of bronchoscopy. The nurse's explanation should focus on the insertion of a small tube through the nose or mouth into the bronchi to visualize the airways. This information helps the patient understand the basic process and what to expect during the procedure. Choice B is incorrect as bronchoscopy does not involve breathing a radioactive substance to show diseased areas in the lungs. Choice C is also incorrect as there is no requirement to drink a thick white liquid for bronchoscopy. Choice D is incorrect as dye injection is not a standard part of bronchoscopy, and asking about allergies to dye is irrelevant in this context.
Question 4 of 5
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue. A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty. B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition. C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem. In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.
Question 5 of 5
Clinical manifestations of Huntington’s disease include:
Correct Answer: D
Rationale: The correct answer is D because Huntington's disease is a neurodegenerative disorder that presents with a triad of symptoms: abnormal involuntary movements (chorea), intellectual decline, and emotional disturbances. Chorea is a hallmark feature of Huntington's disease, caused by damage to the basal ganglia. Intellectual decline includes cognitive impairments such as memory loss and executive dysfunction. Emotional disturbances involve mood swings, irritability, and apathy. Therefore, all three manifestations are commonly seen in individuals with Huntington's disease, making D the correct choice. Choices A, B, and C are incorrect individually because they do not encompass all the key clinical features of Huntington's disease.
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