Fundamentals Nursing Process Questions

Questions 75

ATI RN

ATI RN Test Bank

Fundamentals Nursing Process Questions Questions

Question 1 of 5

A client is brought to the emergency department in an unconscious condition. The client�s wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?

Correct Answer: A

Rationale: The correct answer is A: Client�s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.

Question 2 of 5

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.

Question 3 of 5

Which of the ff would describe the discomfort experienced by a client with a tension headache?

Correct Answer: B

Rationale: The correct answer is B because tension headaches typically present as a feeling of pressure or steady constriction on both sides of the head. This is due to muscle tension in the head and neck. Choice A is incorrect as sensitivity to light is more characteristic of migraines. Choice C is incorrect as unilateral paralysis is not typically associated with tension headaches. Choice D is incorrect as vague headache especially peri orbital is not a common symptom of tension headaches. Therefore, the best description of discomfort experienced by a client with a tension headache is the pressure or steady constriction on both sides of the head.

Question 4 of 5

The nurse is reviewing a patient�s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient�s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise the collaborative problem part of the diagnostic statement because "Impaired physical mobility related to tibial fracture as evidenced by patient�s inability to ambulate" is a nursing diagnosis, not a collaborative problem. Collaborative problems involve issues that require both nursing and medical interventions, whereas nursing diagnoses focus on the nurse's role in addressing the patient's health issues. Therefore, the nurse should revise the collaborative problem part to accurately reflect the collaborative aspect of the patient's care. Etiology (A), nursing diagnosis (B), and defining characteristic (D) are not the parts of the diagnostic statement that need revision in this scenario.

Question 5 of 5

The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?

Correct Answer: A

Rationale: The correct answer is A: Nystagmus. A phenytoin blood level of 35 mcg/ml is above the therapeutic range (usually 10-20 mcg/ml). Excessive levels can lead to symptoms such as nystagmus, which is an involuntary eye movement commonly seen with phenytoin toxicity. Nystagmus is a known side effect of phenytoin overdose. Choices B and C are incorrect because a level of 35 mcg/ml is not within the normal therapeutic range, so symptoms would be expected. Choice D, Slurred speech, is not typically associated with phenytoin toxicity.

Similar Questions

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.

Call to Action Image