which of the following statements does not apply to a nursing plan of care
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 1

1. Which of the following statements does NOT apply to a nursing plan of care?

Correct answer: B

Rationale: The correct answer is B. A nursing plan of care is developed by the nursing staff, not the patient's physician. Choice A is correct as nursing plans of care typically include short-term goals to address immediate patient needs. Choice C is correct because nursing plans of care must be continually evaluated and adjusted based on the patient's progress. Choice D is incorrect as nursing plans of care can include both short-term and long-range goals to address the patient's overall health and well-being.

2. The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position:

Correct answer: A

Rationale: The correct way to carry an infant with cerebral palsy experiencing muscle hypertonicity and scissoring of the legs is astride one of the mother's hips. This position helps keep the infant's legs apart, reducing muscle tightness. Strapping the infant in an infant seat, wrapping tightly in a blanket, or using the football hold under the arm does not address the specific needs related to muscle hypertonicity and scissoring of the legs in cerebral palsy.

3. In patients with heart failure, which type of diet is most recommended?

Correct answer: B

Rationale: A low-sodium diet is most recommended for patients with heart failure. This type of diet helps manage fluid retention by reducing the amount of sodium in the body, which in turn decreases the workload on the heart. High-sodium diets can lead to fluid retention and worsen heart failure symptoms. High-fat and low-carbohydrate diets are not specifically recommended for heart failure patients as the focus is primarily on controlling sodium intake.

4. The HCP orders cultures of the urethral urine, bladder urine, and prostatic fluid. Which instructions would the nurse teach to achieve the first two (2) specimens?

Correct answer: A

Rationale: To obtain accurate cultures of urethral and bladder urine, the nurse should instruct the patient to collect the first 15 mL of urine in one container and the subsequent 50 mL in another. This method ensures that the specimens are separated appropriately for analysis. Choices B, C, and D are incorrect because collecting three early morning urine specimens, massaging the prostate, or collecting a routine urine specimen would not provide the specific separation of urethral and bladder urine required for this particular test.

5. What is the mission of the Army Medical Department?

Correct answer: C

Rationale: The correct answer is C: 'Maintain the health of the Army and conserve its fighting strength.' This mission statement reflects the primary goal of the Army Medical Department, which is to ensure the overall health and readiness of military personnel. Choices A, B, and D are incorrect because they do not fully capture the core purpose of the Army Medical Department. While providing physical examinations, healthcare in disaster areas, and education/training are important aspects, the central mission is to uphold the health and combat readiness of the Army.

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