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
Which of the ff. is the best explanation of emphysema for a newly diagnosed patient?
Correct Answer: B
Rationale: The correct answer is B because emphysema is characterized by the destruction of the alveoli walls, leading to a loss of elasticity in the lungs. This results in air becoming trapped in the lungs, making it difficult to exhale properly. Explanation for why the other choices are incorrect: A: Inflamed bronchioles causing secretions describe bronchitis, not emphysema. C: Damage to the blood supply isn't a primary feature of emphysema; it's more about lung tissue destruction. D: Large dilated sacs of sputum in the lungs is not an accurate description of emphysema; it's more related to bronchiectasis.
Question 4 of 5
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation. Incorrect Choices: A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns. C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication. D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.
Question 5 of 5
What is the primary purpose of the implementation step in the nursing process?
Correct Answer: B
Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.