ATI RN
Nursing Process Final Exam Questions Questions
Question 1 of 9
Which of the following is information the nurse would be correct in giving the patient about smoking and its effect on BP?
Correct Answer: A
Rationale: The correct answer is A: It is associated with stages 1 and 2 hypertension. Smoking is a major risk factor for developing hypertension, especially stages 1 and 2. Nicotine in cigarettes can lead to vasoconstriction, increased heart rate, and overall elevated blood pressure. This information is crucial for patients to understand the direct impact of smoking on their blood pressure levels. Choice B is incorrect because smoking does indeed affect BP regulation by causing vasoconstriction and elevated heart rate. Choice C is incorrect as smoking actually causes vasoconstriction rather than vasodilation. Choice D is incorrect because smoking does lead to sustained elevation of blood pressure, especially in the long term.
Question 2 of 9
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
Correct Answer: D
Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.
Question 3 of 9
A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
Correct Answer:
Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.
Question 4 of 9
A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
Correct Answer: B
Rationale: The correct answer is B: Creamy white patches. These patches are indicative of oral thrush, a common fungal infection seen in individuals with weakened immune systems like those with AIDS. This infection is caused by Candida albicans. It presents as white patches on the tongue, inner cheeks, or roof of the mouth. Halitosis (A) is bad breath, not specific to AIDS. Carious teeth (C) refers to cavities, not directly related to AIDS. Swollen lips (D) can be a symptom of various oral conditions, but not specific to AIDS. In summary, creamy white patches are a characteristic oral problem associated with AIDS due to opportunistic infections like oral thrush.
Question 5 of 9
A client asks the nurse what PSA is. The nurse should reply that is stands for:
Correct Answer: A
Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use. Summary of Incorrect Choices: B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels. C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening. D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.
Question 6 of 9
A female client age 66 is admitted ff a nephrolithomy. One of her laboratory tests reveals a urinary tract infection. Which would be the best nursing action in her case?
Correct Answer: C
Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation. Incorrect Choices: A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection. B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection. D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.
Question 7 of 9
A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
Correct Answer: C
Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.
Question 8 of 9
To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium:
Correct Answer: C
Rationale: Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia. Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome. Step 4: Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms. Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.
Question 9 of 9
The nurse is aware that multiple sclerosis is a progressive disease of the central nervous system characterized by:
Correct Answer: D
Rationale: Step 1: Multiple sclerosis (MS) is a progressive disease affecting the central nervous system. Step 2: Axon degeneration occurs in MS, leading to impaired nerve signal transmission. Step 3: MS is characterized by sclerosed patches, or plaques, in the nervous system. Step 4: Demyelination of the brain and spinal cord is a hallmark feature of MS. Step 5: Therefore, all of the above choices are correct as they accurately describe key features of MS.