Nursing Process Final Exam Questions

Questions 71

ATI RN

ATI RN Test Bank

Nursing Process Final Exam Questions Questions

Question 1 of 5

A client with Hashimoto�s thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client�s cardiac history, the nurse would expect that the client�s initial dose for the thyroid replacement would be which of the following?

Correct Answer: A

Rationale: The correct answer is A: 25 g/day, initially. In this scenario, the client with Hashimoto's thyroiditis and a history of cardiac issues requires a cautious approach due to the risk of exacerbating cardiac conditions with thyroid hormone replacement. Starting with a low dose of 25 �g/day allows for careful monitoring of the client's response and prevents potential adverse effects on the cardiovascular system. Summary: B: Delayed until after thyroid surgery - Not appropriate as the client requires thyroid replacement therapy for Hashimoto's thyroiditis. C: 100 �g/day, initially - Too high of an initial dose and may lead to adverse cardiovascular effects. D: Initiated before thyroid surgery - Not relevant to the client's situation as there is no indication for thyroid surgery mentioned in the question.

Question 2 of 5

Which nursing action is most appropriate for the weak patient with osteoporosis?

Correct Answer: B

Rationale: The correct answer is B: Ambulate with assistance. Ambulating helps prevent further bone loss and strengthens muscles, important for osteoporosis patients. Bedrest can worsen bone density loss. Encouraging fluids and providing a high-protein diet are important for overall health but do not directly address the weakness associated with osteoporosis.

Question 3 of 5

A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:

Correct Answer: D

Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.

Question 4 of 5

Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?

Correct Answer: D

Rationale: The correct answer is D because using two pillows to raise the head can increase the risk of venous stasis and thrombosis in a client with polycythemia vera. This condition involves an increased production of red blood cells, leading to thicker blood and potential clot formation. Elevating the head too much can impede blood flow, exacerbating the risk of clotting. Choices A, B, and C are all appropriate statements indicating good self-care practices and physical activity, which are beneficial for clients with polycythemia vera to improve circulation and overall health.

Question 5 of 5

What is the primary purpose of the implementation step in the nursing process?

Correct Answer: B

Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.

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