ATI RN
Nursing Process Practice Questions Questions
Question 1 of 5
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life. Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.
Question 2 of 5
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse�s actions?
Correct Answer: D
Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on the scope of their practice. By identifying specific patient problems and their potential causes, nurses can provide appropriate interventions and evaluate patient outcomes effectively. This process enhances the quality of care delivery and promotes patient safety. A: This is incorrect because nursing diagnoses are not meant to be a language exclusive to nurses but rather a standardized way to communicate patient data. B: This is incorrect as nursing diagnoses are not about distinguishing roles but rather about identifying and addressing patient problems. C: This is incorrect as nursing diagnoses are based on evidence and critical thinking, not solely on intuition.
Question 3 of 5
Which of the following statements would be most appropriate when assisting a patient who has the nursing diagnosis ofAltered Thought Process with Persona! Hygiene Needs?
Correct Answer: D
Rationale: Rationale: - Choice D is correct as it offers the patient autonomy and promotes self-care, which is important for maintaining independence and dignity. - By giving the patient a choice between brushing their own teeth or having assistance, it empowers them to make decisions. - Choices A, B, and C are not as appropriate because they do not address the patient's autonomy and may come across as directive or intrusive, which can further exacerbate the altered thought process.
Question 4 of 5
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
Correct Answer: B
Rationale: The correct answer is B because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.
Question 5 of 5
A 27-year old adult is admitted for treatment of Crohn�s disease. Which information is most significant when the nurse assesses nutritional health?
Correct Answer: A
Rationale: The correct answer is A: Anthropometric measurements. This includes height, weight, and body mass index, which are crucial indicators of the nutritional status of a patient with Crohn's disease. It helps assess malnutrition, muscle wasting, and overall nutritional health. Dry skin (B), bleeding gums (C), and facial rubor (D) are not direct indicators of nutritional health in a patient with Crohn's disease. Dry skin may indicate dehydration, bleeding gums may suggest poor oral hygiene or gum disease, and facial rubor may be a sign of inflammation but are not specific to nutritional status.
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