ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
Which of the following terms indicates that the patient has a hearing loss caused by aging?
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
Question 2 of 5
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?
Correct Answer: D
Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal
Question 3 of 5
The lowest fasting plasma glucose level suggestive of a diagnosis of diabetes is:
Correct Answer: B
Rationale: The correct answer is B (126mg/dl) because a fasting plasma glucose level ≥126mg/dl is diagnostic of diabetes. The diagnostic criteria for diabetes include a fasting plasma glucose level ≥126mg/dl on two separate occasions. Choices A, C, and D are incorrect because they do not meet the diagnostic threshold for diabetes. A (90mg/dl) is within the normal range, C (115mg/dl) is elevated but not diagnostic, and D (180mg/dl) is too high but not necessary for diagnosis. It's crucial to understand the specific diagnostic criteria to accurately identify diabetes.
Question 4 of 5
A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
Correct Answer: A
Rationale: The correct answer is A: emergency. Acute appendicitis is a condition that requires immediate surgical intervention to prevent complications like rupture. In an emergency surgery, the procedure must be done urgently to treat a life-threatening condition. In this case, the patient's symptoms indicate an urgent need for surgery to remove the inflamed appendix. Choice B: urgent, implies that surgery is needed promptly, but not immediately to prevent life-threatening complications. Choice C: elective, refers to a planned, non-urgent surgery that is scheduled in advance. Choice D: required, is a vague term and doesn't specify the urgency of the surgery, hence it is not the best classification for acute appendicitis surgery.
Question 5 of 5
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds – Important but not the priority in this specific situation. C: Capillary refill – Useful for assessing circulation but not urgent in this context. D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.