ATI RN
ATI Fundamentals Assessment Exam Midterm Questions
Question 1 of 5
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin with erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer?
Correct Answer: D
Rationale: The correct answer is D: Stage II. In a Stage II pressure ulcer, there is a break in the skin that can manifest as a blister or shallow crater. The presence of erythema, serosanguineous drainage, and blister-like appearance in the sacral area indicates partial-thickness skin loss, characteristic of a Stage II pressure ulcer. This stage involves damage to the epidermis and/or dermis, with symptoms such as pain, warmth, and swelling.
Incorrect choices:
A: Stage IV – This stage involves full-thickness tissue loss with exposed bone, tendon, or muscle, which is not indicated by the described findings.
B: Stage III – This stage involves full-thickness tissue loss with visible fat, but the presence of a blister-like appearance suggests partial-thickness skin loss.
C: Stage I – This stage involves intact skin with non-blanchable erythema, not a break in the skin with blister-like features as described.
Question 2 of 5
The nurse knows the importance of assessing vital signs is to:
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Assessing vital signs is crucial to:
A) Evaluate the client's responses to treatment by monitoring changes in heart rate, blood pressure, etc.;
C) Monitor risks for alterations in health by detecting early signs of deterioration;
D) Establish a baseline for comparison in future assessments.
Choice B is incorrect because assessing vital signs is not solely to follow orders.
Choices E, F, and G are not provided.
Question 3 of 5
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?
Correct Answer: A
Rationale: The correct answer is A: Refer the client for medical follow-up. The client presenting with symptoms of fatigue, thirst, frequent urination, and physical signs of Acanthosis Nigricans indicates potential underlying health issues like diabetes. Referring the client for medical follow-up allows for further evaluation, diagnosis, and appropriate management. Option B is incorrect as the symptoms do not directly suggest a family history of cancer. Option C is incorrect as these findings are not benign and indicate a need for further assessment. Option D is not the immediate next step; however, it is essential to perform a blood sugar test as part of the evaluation process.
Question 4 of 5
In which disease process should a nurse expect to see a patient with the presence of pitting edema?
Correct Answer: B
Rationale: The correct answer is B: Liver disease. In liver disease, there is a decrease in protein synthesis, leading to a decrease in plasma oncotic pressure. This results in fluid shifting from the intravascular space to the interstitial space, causing pitting edema. In diabetes mellitus, there may be peripheral edema due to vascular complications, but it is usually not pitting. End-stage renal disease can lead to edema, but it is typically not pitting. Colon cancer does not directly cause pitting edema.
Question 5 of 5
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?
Correct Answer: B
Rationale: The correct answer is B: In the midline, a few centimeters behind the tip of the mandible. The submental lymph nodes are located in the midline, beneath the chin and a few centimeters behind the tip of the mandible. Palpating these lymph nodes in this area allows for accurate assessment of any enlargement or tenderness.
Choice A is incorrect as the lymph nodes in front of the ear are the preauricular lymph nodes.
Choice C is incorrect as the lymph nodes superficial to the sternomastoid are the superficial cervical lymph nodes.
Choice D is incorrect as the lymph nodes at the angle of the mandible are the posterior auricular lymph nodes.