Nursing Process Questions

Questions 75

ATI RN

ATI RN Test Bank

Nursing Process Questions Questions

Question 1 of 5

The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Correct Answer: C

Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy. Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS. Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent. Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.

Question 2 of 5

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection. 2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue. 3. It is a direct intervention that addresses the patient's poor wound healing. 4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process. 5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care. 6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.

Question 3 of 5

When a neurologist asks a patient to smile, which cranial nerve is being tested?

Correct Answer: C

Rationale: Step-by-step rationale: 1. The cranial nerve responsible for facial expression is CN VII, the facial nerve. 2. When a neurologist asks a patient to smile, they are testing the function of CN VII. 3. CN II (optic nerve) is responsible for vision, not facial expression. 4. CN X (vagus nerve) is responsible for various functions like heart rate and digestion, not facial expression. 5. CN XI (accessory nerve) is responsible for shoulder movement, not facial expression. Summary: Testing a patient's ability to smile involves assessing the function of CN VII, the facial nerve. Choices A, B, and D are incorrect as they are associated with different functions and not responsible for controlling facial muscles.

Question 4 of 5

Monthly examination (BSE) can help in early detection of breast CA. When do you perform BSE?

Correct Answer: A

Rationale: The correct answer is A: once a month after menstruation. Performing BSE at this time helps ensure consistent examination when breasts are less tender or swollen, making it easier to detect abnormalities. Performing it once a month ensures regular monitoring for any changes. Choices B, C, and D are incorrect because they do not provide the recommended frequency or timing for an effective BSE. BSE should be done monthly after menstruation to increase the chances of early detection of breast cancer.

Question 5 of 5

Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?

Correct Answer: B

Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures. Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.

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