Questions 9

ATI RN

ATI RN Test Bank

Nursing Process Quizlet Questions Questions

Question 1 of 5

Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Correct Answer: C

Rationale: The correct answer is C: Neck vein distention. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia, causing fluid overload. This can manifest as neck vein distention due to increased venous pressure. Tetanic contractions (A) and weight loss (B) are not typical complications of SIADH; tetany is more associated with hypocalcemia and weight loss is not a common manifestation. Polyuria (D) is actually the opposite of what is seen in SIADH, which is characterized by water retention and concentrated urine.

Question 2 of 5

Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Correct Answer: C

Rationale: The correct answer is C: Neck vein distention. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia, causing fluid overload. This can manifest as neck vein distention due to increased venous pressure. Tetanic contractions (A) and weight loss (B) are not typical complications of SIADH; tetany is more associated with hypocalcemia and weight loss is not a common manifestation. Polyuria (D) is actually the opposite of what is seen in SIADH, which is characterized by water retention and concentrated urine.

Question 3 of 5

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

Correct Answer: A

Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy. Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.

Question 4 of 5

A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

Correct Answer: B

Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.

Question 5 of 5

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe. 2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention. 3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue. 4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking. Summary: - Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking. - Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database. - Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation. - Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.

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