Nursing Process Questions

Questions 75

ATI RN

ATI RN Test Bank

Nursing Process Questions Questions

Question 1 of 5

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:

Correct Answer: B

Rationale: The correct answer is B: Profound neuromuscular irritability. In hypoparathyroidism, there is a decrease in parathyroid hormone leading to low calcium levels. This can result in neuromuscular irritability such as muscle cramps, spasms, and tingling. Monitoring for neuromuscular symptoms is crucial as they can progress to severe complications like seizures. Choices A, C, and D are incorrect because hypoparathyroidism does not typically present with severe hypotension, excessive thirst, or acute gastritis. Monitoring for signs of hypocalcemia and neuromuscular irritability is essential in managing hypoparathyroidism.

Question 2 of 5

Which information indicates a nurse has a good understanding of a goal? It is a statement describing the patient�s accomplishments without a time

Correct Answer: D

Rationale: Step 1: A goal should be measurable to track progress effectively. Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome. Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound. Step 4: Other choices lack the specificity and measurability required for a clear goal. Step 5: Choice A talks about restriction, which is not directly related to understanding a goal. Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal. Step 7: Choice C is vague and lacks the specificity of a measurable outcome.

Question 3 of 5

Choose the condition that exhibits blood values with a low pH and a high PCO :

Correct Answer: A

Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO? and decreased pH. 2. Low pH indicates acidosis, and high PCO? indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO?. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.

Question 4 of 5

Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

Correct Answer: C

Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease. Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.

Question 5 of 5

A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?

Correct Answer: D

Rationale: The correct answer is D: Conjunctivae. Pallor is best assessed in the conjunctivae due to the transparent nature of the tissue, allowing for easy observation of paleness. The conjunctivae are the mucous membranes lining the inner surface of the eyelids and covering the sclera. Anemia can cause decreased hemoglobin levels, resulting in paleness of the mucous membranes. Assessing the scalp (A), chest (B), or axillae (C) may not provide a clear indication of pallor related to anemia. The conjunctivae offer a direct and reliable site to assess for pallor in patients with anemia.

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