ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
Correct Answer: C
Rationale: The correct answer is C: Diagnostic reasoning. Diagnostic reasoning involves using assessment data and critical thinking skills to develop a nursing diagnosis. This process includes analyzing and interpreting data to make clinical judgments about the patient's health status. A: Assigning clinical cues is incorrect because this refers to identifying and documenting specific observations or findings during the assessment process, not the process of developing a nursing diagnosis. B: Defining characteristics is incorrect because this refers to the specific symptoms or manifestations used to support a nursing diagnosis, not the overall process of diagnostic reasoning. D: Diagnostic labeling is incorrect because this refers to assigning a formal name to the nursing diagnosis, not the process of critically analyzing assessment data to develop it.
Question 2 of 5
During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
Correct Answer: B
Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections. Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis. Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain. Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management. Summary: A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer. C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis. D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.
Question 3 of 5
Emil, just had a thyroidectomy this morning. Upon awakening, he complains of circumoral tingling, has a positive Chvostek�s sign and positive Trousseau�s sign. Nurse Ofel assesses this to be an indication of:
Correct Answer: A
Rationale: Rationale: The correct answer is A, overstimulation of the parathyroid hormone. After a thyroidectomy, there is a risk of unintentional damage to the parathyroid glands, leading to hypoparathyroidism. Circumoral tingling, positive Chvostek�s sign, and positive Trousseau�s sign are classic signs of hypocalcemia resulting from parathyroid insufficiency. Choices B, C, and D are incorrect because they do not explain the specific symptoms observed in Emil, which are indicative of low calcium levels due to parathyroid dysfunction.
Question 4 of 5
Which method of data collection will the nurse use to establish a patient�s database?
Correct Answer: C
Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.
Question 5 of 5
A form of cancer therapy wherein a beam of high-energy electromagnetic radiation desires the cancer ceils?
Correct Answer: B
Rationale: The correct answer is B: radiation therapy. Radiation therapy uses high-energy radiation to target and destroy cancer cells while minimizing damage to surrounding healthy tissues. It is a localized treatment that is effective in shrinking tumors and preventing cancer cell growth. Surgery (A) involves physically removing the tumor and surrounding tissues, while chemotherapy (C) uses drugs to kill cancer cells throughout the body. Palliative treatment (D) focuses on symptom management and improving quality of life in advanced stages of cancer. In this case, the focus is on a form of cancer therapy involving high-energy electromagnetic radiation, making radiation therapy the most appropriate choice.
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