ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?
Correct Answer: B
Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation. Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.
Question 2 of 5
The nurse teaches a diabetic client that diet plays a crucial role in managing diabetes mellitus. When evaluating dietary intake, the nurse knows the client is eating the right foods if total daily caloric intake consists of:
Correct Answer: C
Rationale: The correct answer is C (50% to 55% carbohydrate, 35% fat, and 10% to 15% protein) for managing diabetes. Carbohydrates impact blood sugar levels the most, so a moderate intake is crucial. The fat percentage is lower to reduce the risk of cardiovascular issues, common in diabetics. Protein intake is moderate for muscle maintenance. Choice A has higher fat and lower carbohydrate, not ideal for diabetes. Choice B has too high carbohydrate, which can spike blood sugar. Choice D has the highest carbohydrate percentage, which is not recommended for diabetes management.
Question 3 of 5
Hyperparathyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
Correct Answer: A
Rationale: The correct answer is A because hyperparathyroidism is not caused by increased levels of thyroxine but by overactivity of the parathyroid glands. This would lead to symptoms of heat intolerance due to increased metabolism and systolic hypertension due to the effects of excess parathyroid hormone on calcium levels. Choice B is incorrect because diastolic hypertension and widened pulse pressure are not typical symptoms of hyperparathyroidism. Choice C is incorrect because weight gain is not a common symptom of hyperparathyroidism. Choice D is incorrect because anorexia and hyper-excitability are not typical symptoms of hyperparathyroidism.
Question 4 of 5
Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
Correct Answer: C
Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.
Question 5 of 5
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
Correct Answer: B
Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications. A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations. C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process. D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing. In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.