ATI RN
Nursing Process Test Bank Questions
Question 1 of 9
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 2 of 9
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
Question 3 of 9
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
Correct Answer: B
Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.
Question 4 of 9
The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
Correct Answer: C
Rationale: Rationale for Choice C (Correct answer): - In type II DM, there is some insulin present but it is insufficient to meet the body's needs. - Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy. - This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA). - Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. Summary of other choices: - Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient. - Choice B is incorrect as type II diabetics do have fat and protein reserves. - Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.
Question 5 of 9
A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.
Correct Answer: B
Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention. Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless. Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand. Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.
Question 6 of 9
The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording
Correct Answer: C
Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.
Question 7 of 9
When caring for Mr. Reyes, the nurse should assess for
Correct Answer: B
Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues. A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario. C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness. D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.
Question 8 of 9
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
Correct Answer: C
Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.
Question 9 of 9
The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:
Correct Answer: B
Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.