ATI RN
Nursing Process 1 Test Questions Questions
Question 1 of 5
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Acute pain. The patient's right femur fracture would likely cause significant pain. Treating the pain is a priority to ensure the patient's comfort and promote healing. Posttrauma syndrome (A) is more applicable for patients experiencing emotional distress following a traumatic event. Constipation (B) may be a concern due to immobility but is not as immediate as managing pain. Anxiety (D) may be present but addressing the acute pain would likely alleviate some anxiety as well.
Question 2 of 5
A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
Correct Answer: C
Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows: 1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management. 2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery. 3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life. 4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.
Question 3 of 5
During a routine check-up, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
Correct Answer: C
Rationale: The correct answer is C: Joint abnormalities. In rheumatoid arthritis, joint abnormalities such as swelling, warmth, and tenderness are the hallmark manifestations. Assessing joint abnormalities first is crucial as they are the primary clinical signs of the disease. Muscle weakness (A) is a common symptom but typically occurs later due to joint inflammation and disuse. Painful subcutaneous nodules (B) are present in some cases but are not as common or prominent as joint abnormalities. Gait disturbances (D) may occur as a result of joint damage, but they are secondary to the primary manifestation of joint abnormalities. By prioritizing the assessment of joint abnormalities, the nurse can promptly identify and address the most prevalent disease manifestations in rheumatoid arthritis.
Question 4 of 5
The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
Correct Answer: D
Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.
Question 5 of 5
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct answer is C. Rolling Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available is the appropriate action. This position helps protect his airway and prevents potential complications from a possible spinal injury. It also allows for better assessment of his condition by healthcare professionals. Choice A is incorrect because leaving Mr. Gabatan on his back and instructing him to move can worsen any spinal injury he may have sustained. Choice B is incorrect because raising him to a sitting position can also exacerbate his condition. Choice D is incorrect because moving him without proper stabilization can lead to further injury.
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