ATI RN
Nursing Process Practice Questions Quizlet Questions
Question 1 of 5
Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:
Correct Answer: C
Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.
Question 2 of 5
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
Correct Answer: D
Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.
Question 3 of 5
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
Correct Answer: C
Rationale: The correct answer is C: administer oxygen via face mask. Given Aling Nena's sudden chest heaviness post-surgery, oxygen administration is the priority to ensure adequate oxygenation. This can help rule out potential respiratory issues or hypoxemia, which are common post-operatively. Providing oxygen promptly can prevent further complications such as respiratory distress or cardiac compromise. Documenting the pain characteristics (choice A) can be done after ensuring immediate physiological needs are met. Offering analgesics (choice B) without confirming the underlying cause can mask symptoms and delay appropriate interventions. Informing the physician (choice D) is important but not as urgent as addressing potential respiratory compromise.
Question 4 of 5
Which of the following medications should then nurse explain may cause headache as a side effect?
Correct Answer: B
Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.
Question 5 of 5
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
Correct Answer: B
Rationale: The correct answer is B: To provide a means for further comparison and evaluation. By recording the color of drainage from each tube and catheter, the nurse can monitor changes over time, assess for any abnormalities, and evaluate the effectiveness of treatment. This helps in detecting complications early and making informed decisions. Rationale for other choices: A: To restore and maintain intravascular volume - Monitoring drainage color does not directly relate to intravascular volume status. C: To avoid interference with wound drainage - Monitoring drainage color does not prevent interference with wound drainage. D: To prevent pain related to obstruction - Monitoring drainage color does not directly prevent pain related to obstruction.
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