ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 5
The following are known to be causes of hepatitis except:
Correct Answer: C
Rationale: The correct answer is C: bacteria. Hepatitis is primarily caused by viruses (such as Hepatitis A, B, C), toxins (like alcohol or certain medications), and chemicals/drugs. Bacteria do not typically cause hepatitis as it is a viral infection that affects the liver. Therefore, choice C is the exception among the listed causes. Viruses directly target liver cells, toxins can damage the liver, and certain chemicals/drugs can lead to liver inflammation. Hence, bacteria do not play a significant role in causing hepatitis.
Question 2 of 5
A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client’s signs/symptoms is:
Correct Answer: A
Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.
Question 3 of 5
JR is admitted to the medical-surgical unit because of a diagnosis of nephritic syndrome. What is the hallmark of this syndrome?
Correct Answer: C
Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.
Question 4 of 5
The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Correct Answer: D
Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis. Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia. Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium. Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS. Summary: A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS. B: Serum alkalosis is not typically associated with HHNS. C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.
Question 5 of 5
The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:
Correct Answer: C
Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat. A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation. B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation. D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.