ATI RN
Nursing Process Quizlet Questions Questions
Question 1 of 5
What is the rationale for giving Mr. Franco frequent mouth care?
Correct Answer: B
Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco is important to remove dried blood when the tongue is bitten during a seizure. This is crucial for preventing infection and promoting oral hygiene. Choices A, C, and D are incorrect because the primary reason for mouth care in this case is to address the physical consequences of a seizure, such as tongue biting and potential injury, rather than thirst, tactile stimulation, or prevention of oral mucosal issues related to mouth breathing in a comatose patient.
Question 2 of 5
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
Correct Answer: C
Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised. A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis. B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention. D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.
Question 3 of 5
Mr. RR is being prepared for surgery. Nursing care would include:
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Assessment of neurologic signs establishes baseline for post-op care. 2. Helps detect any changes post-surgery. 3. Enables prompt intervention if any issues arise. 4. Planning activities (B) is not a priority pre-surgery. 5. Enema (C) may not be necessary for all surgeries. 6. Explaining complications (D) is important but not a primary pre-op nursing care.
Question 4 of 5
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
Correct Answer: D
Rationale: The correct answer is D, Arcus senilis. This condition does not cause visual problems in the older adult. Arcus senilis is a grayish-white ring around the cornea, which does not affect vision. Glaucoma, macular degeneration, and cataracts are conditions that can lead to visual impairment in older adults. Glaucoma is characterized by increased pressure in the eye, which can damage the optic nerve and lead to vision loss. Macular degeneration affects the central part of the retina, leading to blurred or distorted vision. Cataracts cause clouding of the lens, resulting in decreased vision. Therefore, Arcus senilis is the correct choice as it does not cause visual problems compared to the other conditions listed.
Question 5 of 5
Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?
Correct Answer: C
Rationale: The correct answer is C: Sensorineural hearing loss. Hearing aids are most effective for sensorineural hearing loss as they amplify sound signals to compensate for damage to the inner ear hair cells or auditory nerve. This type of hearing loss is due to problems in the inner ear or auditory nerve, which can be partially compensated for by using hearing aids. The other choices, A: Conductive, B: Mixed, and D: Central, are not as effectively improved by hearing aids. Conductive hearing loss is usually due to problems in the outer or middle ear, which can often be treated with medical or surgical interventions. Mixed hearing loss involves a combination of conductive and sensorineural components, and may require a combination of interventions. Central hearing loss is due to problems in the central auditory pathways in the brain, and is not typically improved by hearing aids.