ATI RN
Nursing Process Questions and Answers PDF 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. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process. B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully. C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood. D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
Question 2 of 9
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
Correct Answer: B
Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.
Question 3 of 9
. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?
Correct Answer: A
Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.
Question 4 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. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process. B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully. C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood. D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
Question 5 of 9
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity. A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures. B: Use of tilt board may not directly address the need for proper positioning to prevent contractures. C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.
Question 6 of 9
The spouse of a client with gastric cancer expresses concern that the couple’s children may develop this type of cancer when they’re older. When reviewing risk factors for gastric cancer with the client and family, the nurse explains that a certain blood type increases the risk by 10%. The nurse is referring to:
Correct Answer: A
Rationale: The correct answer is A: Type A. Individuals with blood type A have a slightly higher risk of developing gastric cancer compared to other blood types. This is due to the presence of certain antigens associated with Type A blood that may increase susceptibility to gastric cancer. In this case, the nurse mentions a 10% increased risk for individuals with Type A blood, which aligns with the known epidemiological data. Choice B: Type AB is incorrect because individuals with Type AB blood do not have a known increased risk of gastric cancer. Choice C: Type B is incorrect because individuals with Type B blood do not have a known increased risk of gastric cancer. Choice D: Type O is incorrect because individuals with Type O blood actually have a slightly lower risk of developing gastric cancer compared to individuals with Type A blood.
Question 7 of 9
When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
Correct Answer: C
Rationale: The correct answer is C: Weak, slow pulse. Circulatory overload typically presents with signs of fluid volume excess, such as moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse is not a characteristic sign of circulatory overload, as the heart rate may actually be elevated due to the increased fluid volume. Therefore, a weak, slow pulse would not be likely to occur in this scenario.
Question 8 of 9
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She’s fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for this client is C: Deficient fluid volume related to osmotic diuresis induced by hypernatremia. The client's elevated sodium level of 152mEq/L indicates hypernatremia, which leads to osmotic diuresis and subsequent fluid loss. This results in deficient fluid volume, causing the client to urinate frequently and experience fatigue from lack of sleep. The other choices are incorrect because: A: Deficient fluid volume related to inability to conserve water is not the most appropriate diagnosis as the primary issue is the osmotic diuresis induced by hypernatremia, not the client's inability to conserve water. B: Imbalanced nutrition: Less than body requirements related to hypermetabolic state is not the most appropriate diagnosis as the client's weight loss is likely due to fluid loss from osmotic diuresis, not a hypermetabolic state. D: Imbalanced nutrition: Less than body requirements related to catab
Question 9 of 9
A nurse evaluates a client’s response to a nursing intervention and determines that the expected outcome was not achieved. What is the nurse’s most appropriate action?
Correct Answer: D
Rationale: The correct answer is D: Reassess the client's condition. When an expected outcome is not achieved, the nurse must reassess the client's condition to identify the reasons for the lack of success. This step allows the nurse to gather more information, adjust the plan of care if necessary, and determine the most suitable course of action to help the client achieve the desired outcome. Choice A: Terminating the plan of care is premature without reassessing the client's condition and identifying potential barriers to success. Choice B: Modifying the plan of care may be necessary after reassessment but should not be the first step. Choice C: Reassigning care to another nurse does not address the underlying issues affecting the client's response to the intervention.