ATI RN
Nursing Process Exam Questions Questions
Question 1 of 9
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
Question 2 of 9
Mr. Galino is diagnosed to have Raynaud’s disease. Nurse Oliver gives instructions to the client to stop smoking because it causes:
Correct Answer: B
Rationale: The correct answer is B: vasoconstriction, vasospasms. 1. Raynaud's disease involves exaggerated vasoconstriction and vasospasms of blood vessels in response to cold or stress. 2. Smoking aggravates vasoconstriction and vasospasms by constricting blood vessels further. 3. This can worsen symptoms for individuals with Raynaud's disease. 4. Choices A, C, and D do not directly relate to the mechanism of Raynaud's disease and smoking.
Question 3 of 9
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
Correct Answer: D
Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.
Question 4 of 9
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.
Question 5 of 9
What is the mineral necessary for chemical clotting?
Correct Answer: D
Rationale: The correct answer is D: Calcium. Calcium is necessary for the chemical clotting process because it plays a crucial role in the activation of various clotting factors, leading to the formation of a blood clot. Without sufficient calcium, the clotting cascade would not be able to proceed effectively. Iron (choice A) is essential for red blood cell production, not clotting. Potassium (choice B) and Sodium (choice C) are important for various physiological functions but are not directly involved in the clotting process.
Question 6 of 9
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
Correct Answer: D
Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.
Question 7 of 9
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
Correct Answer: D
Rationale: The correct answer is D because dysplasia refers to the alteration in the size, shape, and organization of differentiated cells. Dysplasia is an abnormal growth or development of cells that can be a precursor to cancer. It is characterized by changes in cell size, shape, and organization, which can be seen in Papanicolaou tests. Choice A is incorrect because it describes an undifferentiated tumor, not dysplasia. Choice B is incorrect as it describes hyperplasia, not dysplasia. Choice C is incorrect as it refers to metaplasia, not dysplasia. In summary, dysplasia is specifically about the abnormal changes in the appearance and organization of differentiated cells, making choice D the correct definition.
Question 8 of 9
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship. Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.
Question 9 of 9
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
Correct Answer: A
Rationale: Rationale: 1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty. 2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring. 3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care. 4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care. Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.