which of the following describes the four step method of assessment planning implementation and evaluation
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation in nursing is a continuous and cyclical process. Choice A is incorrect because the method is not solely problem-focused; it involves a comprehensive approach. Choice B is incorrect as it does not capture the cyclical nature of the process. Choice D is incorrect as the method is systematic and not based on trial-and-error but rather evidence-based practice.

2. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

Correct answer: C

Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.

3. The client is four hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client?

Correct answer: B

Rationale: Assessing the client’s bilateral pedal pulses is crucial at this point to monitor the perfusion to the lower extremities after abdominal aortic aneurysm repair surgery. Ambulation (Choice A) may be appropriate but should be guided by the assessment findings. Maintaining a continuous IV heparin drip (Choice C) is not typically indicated post-operatively for this type of surgery. Providing clear liquids (Choice D) may not be suitable immediately after the surgery, as the client needs time to recover before resuming oral intake.

4. Which of the following drugs may cause weight gain?

Correct answer: B

Rationale: The correct answer is B, Steroids. Steroids are known to cause weight gain as a side effect. Amphetamines, choice A, are more likely to cause appetite suppression and weight loss. Antibiotics, choice C, and nonsteroidal anti-inflammatory drugs, choice D, are not typically associated with weight gain as a common side effect.

5. The nurse is teaching the client diagnosed with colon cancer who is scheduled for a colostomy the next day. Which behavior indicates the best method of applying adult teaching principles?

Correct answer: A

Rationale: Choice A is the correct answer because repeating information and addressing the client’s questions as they arise is an effective method for reinforcing learning in adults. This approach allows for immediate clarification and reinforcement of important points. Choice B is incorrect because teaching all the information in one session may be overwhelming for the client and hinder retention. Choice C is incorrect as using a video with medical terms may not necessarily address the client's specific questions or concerns. Choice D is also incorrect because waiting for the client to ask questions may lead to missed opportunities for providing crucial information and addressing uncertainties.

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