ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
The clinical manifestations of Parkinson’s disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:
Correct Answer: C
Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.
Question 2 of 9
A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?
Correct Answer: C
Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.
Question 3 of 9
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 4 of 9
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.
Question 5 of 9
An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?
Correct Answer: C
Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.
Question 6 of 9
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer): - In type II DM, there is some insulin present but it is insufficient to meet the body's needs. - Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy. - This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA). - Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. Summary of other choices: - Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient. - Choice B is incorrect as type II diabetics do have fat and protein reserves. - Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
Question 7 of 9
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?
Correct Answer: D
Rationale: The correct answer is D: Sitting at a 45-degree angle to the bed. This position allows the nurse to have a clear view of the client and maintain good communication. Sitting at a 45-degree angle enables the nurse to observe the client's facial expressions, body language, and interact effectively. Standing at the end of the bed (A) limits the nurse's view and communication. Standing at the side of the bed (B) may obstruct the nurse-client interaction. Sitting at least six feet away (C) creates unnecessary distance and hinders effective communication.
Question 8 of 9
Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
Correct Answer: D
Rationale: The correct answer is D because a multilumen pulmonary artery catheter can provide detailed information about preload, afterload, and cardiac output. Preload refers to the volume of blood in the ventricles at the end of diastole, afterload is the resistance the heart has to overcome to eject blood, and cardiac output is the amount of blood pumped by the heart per minute. This catheter allows for direct measurement of these parameters by monitoring pressures in the pulmonary artery. Choices A, B, and C are incorrect individually as they do not encompass the full range of information that can be obtained with a multilumen pulmonary artery catheter.
Question 9 of 9
A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to
Correct Answer: A
Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.