Questions 9

ATI RN

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Nursing Process Questions and Answers PDF Questions

Question 1 of 5

Which of the ff are the symptoms of basilar skull fracture? Choose all that apply

Correct Answer: A

Rationale: The correct answer is A: Raccoon eyes. Basilar skull fracture can result in periorbital bruising, known as raccoon eyes, due to blood pooling in the soft tissues around the eyes. This occurs because the fracture involves the base of the skull near the orbits. Choice B: Amnesia is not a typical symptom of basilar skull fracture. Amnesia may occur in head injuries but is not specific to basilar skull fractures. Choice C: Halo sign is a term used to describe a ring of clear fluid surrounding a blood spot, typically seen in cases of a cerebrospinal fluid leak from the ear or nose, not specific to basilar skull fractures. Choice D: Paresthesia, which refers to abnormal sensations like tingling or numbness, is not a common symptom of basilar skull fractures. It is more associated with nerve damage rather than fractures involving the base of the skull.

Question 2 of 5

A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?

Correct Answer: B

Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms. Incorrect choices: A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels. C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation. D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.

Question 3 of 5

A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?

Correct Answer: D

Rationale: The correct answer is D: Peritonitis. Peritonitis is a major complication of peritoneal dialysis due to infection of the peritoneum. It can lead to serious consequences if not treated promptly. The nurse should monitor for signs of peritonitis such as abdominal pain, cloudy dialysate, fever, and increased white blood cell count. Internal hemorrhage (A), hydronephrosis (B), and ecchymosis (C) are not major complications specific to peritoneal dialysis. Internal hemorrhage can occur but is less common. Hydronephrosis is more related to obstruction of the ureters. Ecchymosis refers to bruising and is not directly associated with peritoneal dialysis.

Question 4 of 5

When testing visual fields, the nurse is assessing which of the following parts of vision?

Correct Answer: A

Rationale: The correct answer is A: Peripheral vision. When testing visual fields, the nurse evaluates the ability to see objects outside the direct line of sight, which is indicative of peripheral vision. Peripheral vision helps detect objects and movement in the side vision. Distance vision (B) refers to the ability to see clearly at a distance, while near vision (C) pertains to close-up vision. Central vision (D) is essential for focusing on details and seeing straight ahead. Therefore, A is the correct choice as it specifically pertains to the assessment of visual fields.

Question 5 of 5

Which of the following is the appropriate nursing diagnosis?

Correct Answer: B

Rationale: The correct answer is B, "Fluid volume deficit R/T uncontrolled vomiting." This option correctly identifies the cause of the fluid volume deficit as uncontrolled vomiting, which is a common reason for fluid loss. The nursing diagnosis should always reflect the underlying cause of the issue. A is incorrect as "furrow tongue" is not a recognized medical term related to fluid volume deficit. C is incorrect because dehydration is not typically related to subnormal body temperature unless it is severe. D is incorrect as incessant vomiting is more specific to the cause, but the term "dehydration" should be used instead of "fluid volume deficit" in this context. In summary, option B is the appropriate nursing diagnosis as it accurately links the fluid volume deficit to the cause of uncontrolled vomiting.

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