Fundamentals Nursing Process Questions

Questions 75

ATI RN

ATI RN Test Bank

Fundamentals Nursing Process Questions Questions

Question 1 of 5

A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.

Correct Answer: C

Rationale: The correct answer is C because asking if the client has strained their voice recently is the most relevant question to assess the issue of hopelessness. Voice strain can be a symptom of underlying emotional distress or mental health concerns, which could be contributing to the client's feelings of hopelessness. Choices A, B, and D are unrelated to the client's presenting issue and would not provide valuable information in addressing the problem at hand.

Question 2 of 5

Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient�s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Question 3 of 5

During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:

Correct Answer: B

Rationale: Step 1: The scenario describes Toni minimizing her visual problems, planning advanced degrees, seeking full-time jobs, and wanting more children. Step 2: Choice B is correct because it recognizes Toni's behavior as a coping mechanism to deal with her illness. Step 3: Minimizing visual problems and focusing on future goals can be a way for Toni to maintain a positive outlook and cope with her challenges. Step 4: Choices A, C, and D are incorrect because they do not address Toni's behavior as a coping mechanism. Choice A mentions euphoria, which is not supported by the scenario. Choice C and D do not acknowledge Toni's coping mechanism but instead focus on different aspects like disease process and physical functioning.

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 is a nursing diagnosis, not a collaborative problem. A collaborative problem involves potential complications that require both nursing and medical interventions. In this case, impaired physical mobility is a nursing diagnosis that requires nursing interventions to address the patient's inability to ambulate. Choices A, B, and D are incorrect because they are all relevant components of a nursing diagnostic statement: A - Etiology identifies the cause of the nursing diagnosis, B - Nursing diagnosis states the health problem, and D - Defining characteristic provides evidence supporting the nursing diagnosis.

Question 5 of 5

The majority of lumbar disc herniations occur at the level of:

Correct Answer: B

Rationale: The correct answer is B: L4-L5. This is because the L4-L5 intervertebral disc segment experiences the highest amount of mechanical stress and mobility in the lumbar spine, making it more prone to herniation. Additionally, nerve roots at this level innervate the lower extremities, making it a common site for symptoms such as sciatica. Choices A, C, and D are incorrect because herniations at those levels are less common due to lower mechanical stress and mobility compared to L4-L5.

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