ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
Correct Answer: B
Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.
Question 2 of 5
A client who is receiving cyclosporine (Sandimmune) must practice good oral hygiene, including regular brushing and flossing of the teeth, to minimize gingival hyperplasia during long-term therapy with certain drugs. Which of the following drug falls into this category?
Correct Answer: B
Rationale: The correct answer is B: Phenytoin (Dilantin). Phenytoin is known to cause gingival hyperplasia as a side effect, which can be minimized with good oral hygiene practices. Procainamide, Azathioprine, and Allopurinol are not associated with gingival hyperplasia. Therefore, the client receiving cyclosporine should focus on practicing good oral hygiene specifically when taking Phenytoin to minimize the risk of developing gingival hyperplasia.
Question 3 of 5
After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.
Question 4 of 5
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
Correct Answer: C
Rationale: Correct Answer: C - Autoimmune disorders include connective tissue (collagen) disorders. Rationale: Autoimmune disorders involve the immune system mistakenly attacking healthy cells and tissues in the body, which can lead to various conditions, including connective tissue disorders like rheumatoid arthritis. Providing this information to the client and family is crucial for understanding the nature of autoimmune disorders and the potential impact on the body. Summary of other choices: A: False-negative or false-positive serologic tests can occur in autoimmune disorders, so this statement is not specific enough to be the most appropriate information to provide. B: Advanced medical interventions can manage symptoms but not cure autoimmune disorders, making this statement inaccurate and misleading. D: Autoimmune disorders can present with a wide range of symptoms and can be challenging to diagnose, but this statement does not address the specific link between autoimmune disorders and connective tissue disorders.
Question 5 of 5
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
Correct Answer: D
Rationale: The correct answer is D (Lamb and peaches) because lamb is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Peaches are high in vitamin C, which enhances iron absorption. Shrimp and tomatoes (A) have some iron but are not as rich in iron as lamb. Cheese and bananas (B) are not significant sources of iron. Lobster and squash (C) also do not provide as much iron as lamb. Overall, the combination of heme iron from lamb and vitamin C from peaches makes them the most suitable choices for an anemic client requiring iron therapy.