ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Question 1 of 5
A nurse is caring for a client who is exhibiting violent behavior and requires the application of wrist restraints. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: Quick-release ties ensure safety by allowing rapid removal in emergencies. A prescription is needed but not the first action. Securing to side rails risks injury, and two fingers (not three) is the correct spacing.
Question 2 of 5
A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: Eyelashes that curl slightly outward are a normal finding in an eye assessment. This natural curl helps protect the eyes from debris and sweat, and it also aids in the distribution of tears across the eye surface. Eyelashes that curl outward are typical and expected in a healthy individual. Corneas with an opaque appearance are not a normal finding. The cornea should be clear and transparent, allowing light to pass through to the retina. An opaque cornea can indicate various conditions such as corneal edema, scarring, or infection.
Therefore, this finding would be abnormal and warrant further investigation. Eyelids that blink involuntarily 30 to 35 times per minute are not within the normal range. The average blink rate for a healthy adult is approximately 15 to 20 times per minute. A significantly higher blink rate could indicate an underlying condition such as dry eye syndrome, blepharospasm, or other neurological issues. Pupils that are 8 to 9 mm in diameter are abnormally large. The normal pupil size ranges from 2 to 4 mm in bright light and 4 to 8 mm in dim light. Pupils that are consistently larger than this range could indicate a condition such as mydriasis, which can be caused by various factors including medications, trauma, or neurological disorders.
Question 3 of 5
A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?
Correct Answer: B
Rationale: Inconsistent sleep disrupts stress management; support groups provide emotional relief; delegation reduces stress; and 1 hour/week exercise is insufficient (150 min/week recommended). Attending a support group reflects understanding.
Question 4 of 5
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
Correct Answer: B,C,E
Rationale: A negative Chvostek's sign is not expected in a client with hypocalcemia. The Chvostek's sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek's sign indicates neuromuscular irritability due to low calcium levels.
Therefore, a negative Chvostek's sign would not be consistent with hypocalcemia. A positive Trousseau's sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau's sign, indicating neuromuscular irritability due to low calcium levels. Muscle cramps are a common symptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort. Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention. Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.
Question 5 of 5
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
Correct Answer: D
Rationale: The NLN focuses on education, The Joint Commission on accreditation, and the Patients Bill of Rights on patient rights. State-based Nurse Practice Acts legally define the scope of nursing practice.