ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
Usually, how does the patient behave after his seizure has subsided?
Correct Answer: B
Rationale: The correct answer is B: Sleeps for a period of time. After a seizure, the brain and body experience fatigue and exhaustion. It is common for the patient to feel drowsy and require rest to recover. This post-ictal state is characterized by sleepiness and confusion. The other choices are incorrect because typically, after a seizure, the patient is not most comfortable walking and moving about (A), does not become restless and agitated (C), and may not immediately express thirst and hunger (D). It is important to ensure the patient is in a safe environment and allow them to rest after a seizure episode.
Question 2 of 5
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 3 of 5
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.
Question 4 of 5
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
Correct Answer: A
Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.
Question 5 of 5
Which of the following would the nurse teach the patient is the most common site for ear infections?
Correct Answer: B
Rationale: The correct answer is B, Middle ear. This is because the middle ear is the most common site for ear infections due to its anatomy, including the Eustachian tube that can easily become blocked, leading to fluid buildup and infection. The outer ear (A) is less susceptible to infections, while the inner ear (C) and semicircular canal (D) are not typically involved in ear infections, as they are more related to balance and hearing functions rather than infection susceptibility.