ATI RN
Nursing Process Test Bank Questions
Question 1 of 5
Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?
Correct Answer: D
Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.
Question 2 of 5
Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
Correct Answer: B
Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.
Question 3 of 5
When can a donor and recipient of blood be considered compatible?
Correct Answer: C
Rationale: The correct answer is C because compatibility between blood donor and recipient is determined by the absence of clumping or hemolysis when both samples are mixed. Clumping indicates an incompatible blood type reaction, leading to potential harm. Blood clots (option B) are not indicative of compatibility but rather a sign of coagulation issues. Blood color change (option A) and blood drop sinking in water (option D) are not reliable indicators of blood compatibility. In summary, option C is correct as it directly assesses for the absence of a harmful reaction, while the other choices do not accurately determine blood compatibility.
Question 4 of 5
What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?
Correct Answer: C
Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections. Now, let's analyze the other choices: A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy. B: Sleep in a semi-fowler’s position - Positioning does not directly impact infection prevention post-splenectomy. D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.
Question 5 of 5
In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?
Correct Answer: A
Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition. Summary of why the other choices are incorrect: B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia. C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia. D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.