ATI RN
Fundamentals of Nursing Nursing Process Questions Questions
Question 1 of 5
A nurse writes the following nursing diagnosis for a client with Alzheimer�s disease: 'Disturbed Thought Processes related to Alzheimer�s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
Correct Answer: A
Rationale: The correct answer is A: "Disturbed thought processes." This is the problem statement because it identifies the client's main issue, which is the disturbance in their thought processes. The "related to" part (B) indicates the cause, "Alzheimer's disease" (C) is the etiology, and "incoherent language" (D) is the evidence. By focusing on the problem statement, the nurse can develop appropriate interventions to address the client's disturbed thought processes.
Question 2 of 5
After surgery the nurse notes that the patient�s urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
Correct Answer: A
Rationale: The correct answer is A: The sympathetic nervous system saves fluid in response to the stress of surgery. The sympathetic nervous system is responsible for the "fight or flight" response, which includes the conservation of fluids during stressful situations. Dark amber and concentrated urine indicates dehydration, which can be a result of the sympathetic nervous system conserving fluids. B: The sympathetic nervous system does not "diereses" (increase urination) in response to stress. C: The parasympathetic nervous system is not involved in fluid conservation during stress. D: The parasympathetic nervous system does not "diereses" fluid in response to stress.
Question 3 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 4 of 5
Other signs of hypovolemia includes all of the following except:
Correct Answer: C
Rationale: The correct answer is C because decreased pulse rate and widened pulse pressure are not signs of hypovolemia. In hypovolemia, the body tries to compensate by increasing the heart rate and narrowing the pulse pressure to maintain adequate blood flow. A is incorrect as dry mucous membranes and soft eyeballs are signs of dehydration. B is incorrect as increased hematocrit and hemoglobin are indicators of hemoconcentration in hypovolemia. D is incorrect as increased lethargy and confusion can be seen in severe hypovolemia due to poor perfusion of vital organs.
Question 5 of 5
In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?
Correct Answer: B
Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.
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