ATI RN
Nursing Process Test Questions Questions
Question 1 of 5
When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?
Correct Answer: D
Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.
Question 2 of 5
Which of the ff. would the nurse explain to a patient is the main purpose of a hearing aid?
Correct Answer: D
Rationale: The correct answer is D: Improve ability to hear. A hearing aid is designed to improve a person's ability to hear by amplifying sound. This helps individuals with hearing loss to better understand speech and sounds in their environment. A: Amplifying background noise is not the main purpose of a hearing aid. It may actually hinder the user's ability to focus on important sounds. B: Amplifying musical sounds is not the primary function of a hearing aid. The main focus is on improving speech understanding. C: Occluding the ear is not the purpose of a hearing aid. It is meant to enhance hearing, not block sound.
Question 3 of 5
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
Correct Answer: C
Rationale: The correct answer is C: Thyroid crisis. These signs suggest thyroid storm, a life-threatening complication of thyroid surgery. The high fever, tachycardia, and restlessness are classic symptoms. Thyroid crisis can lead to severe complications if not managed promptly. A: Diabetic ketoacidosis typically presents with polyuria, polydipsia, and fruity breath odor. B: Hypoglycemia would present with symptoms like diaphoresis, tremors, and confusion. D: Tetany is associated with hypocalcemia and presents with muscle cramps, spasms, and numbness.
Question 4 of 5
Which of the following is the most critical intervention needed for a client with myxedema coma?
Correct Answer: A
Rationale: The correct answer is A: Administering an oral dose of levothyroxine (Synthroid). In myxedema coma, there is severe hypothyroidism leading to altered mental status, hypothermia, and organ failure. Administering levothyroxine is crucial to replace the deficient thyroid hormone rapidly and restore metabolic function. Warming the client (B) is important but secondary to addressing the underlying hormonal imbalance. Measuring intake and output (C) is essential for overall assessment but not the most critical intervention. Maintaining a patent airway (D) is always important in any medical emergency but does not directly address the primary issue of hypothyroidism in myxedema coma.
Question 5 of 5
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
Correct Answer: C
Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.