ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
Question 2 of 9
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis. Explanation of other choices: B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect. C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location. D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,
Question 3 of 9
The activation of B cells in humoral immunity is assisted by which of the following?
Correct Answer: C
Rationale: The correct answer is C: Helper T cells. Helper T cells play a crucial role in activating B cells by releasing cytokines that stimulate B cell proliferation and differentiation. They also help in the production of antibodies. Cytotoxic T cells (A) are involved in cell-mediated immunity, not humoral immunity. Suppressor T cells (B) regulate the immune response and do not directly assist in B cell activation. Neutrophils (D) are phagocytic cells involved in innate immunity, not in activating B cells in humoral immunity.
Question 4 of 9
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds – Important but not the priority in this specific situation. C: Capillary refill – Useful for assessing circulation but not urgent in this context. D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Question 5 of 9
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
Question 6 of 9
Which type of neuron transmits impulses from the central nervous system to the muscles and glands?
Correct Answer: C
Rationale: The correct answer is C: Efferent neurons transmit impulses from the central nervous system to muscles and glands. This is because efferent neurons are responsible for carrying motor signals away from the central nervous system to control muscle movement and gland secretion. Afferent neurons (choice A) transmit sensory information from the body to the central nervous system. Affective (choice B) is not a term used in neuroscience for describing neuron functions. Effective (choice D) is not a term used in neuroscience and does not describe the specific function of transmitting impulses from the central nervous system to muscles and glands.
Question 7 of 9
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.
Question 8 of 9
A brain abscess is a collection of pus within the substance of the brain and is caused by:
Correct Answer: D
Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion occurs when bacteria enter the brain tissue directly, such as through trauma or surgery. Infections from other organs, like the lungs or heart, can spread through the bloodstream to the brain. Infections from nearby sites, such as the ears or sinuses, can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C individually do not cover all the possible causes of a brain abscess, making D the correct choice.
Question 9 of 9
A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
Correct Answer: D
Rationale: The correct evaluative measure is D: Lungs clear to auscultation following use of inhaler. This choice aligns with the expected outcome of having no secretions present in the lungs in 48 hours. By using an inhaler to clear the lungs, the nurse can assess if the expected outcome is being met. This measure directly evaluates the presence of secretions in the lungs, in line with the established goal. Incorrect Choices: A: No sputum or cough present in 4 days - This measure does not align with the expected outcome of having no secretions present in the lungs in 48 hours. B: Congestion throughout all lung fields in 2 days - This indicates a worsening condition and does not demonstrate progress towards the goal. C: Shallow, fast respirations 30 breaths per minute in 1 day - This measure is unrelated to the presence of secretions in the lungs and the goal of avoiding shortness of breath with activity.