ATI RN
Client Health and Safety Specifications Questions
Question 1 of 5
The nurse is filling out an incident report after an older adult client fell while attempting to transfer this person from bed to a commode. Which health problem should the nurse consider when client falls occur?
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. This condition is characterized by a drop in blood pressure when moving from lying down to standing up, leading to dizziness and falls. In the scenario provided, the older adult client fell while attempting to transfer to a commode, indicating a sudden drop in blood pressure upon standing. Bradypnea (A) refers to abnormally slow breathing rate and is not directly related to falls. Palpitations (B) are rapid or irregular heartbeats and do not directly cause falls. Primary hypertension (C) is high blood pressure that is typically asymptomatic and does not directly lead to falls. Therefore, the most likely health problem to consider in this scenario is orthostatic hypotension due to its association with falls during position changes.
Question 2 of 5
What type of logical reasoning is the nurse using when he/she/they starts with the big picture and anticipates specific findings?
Correct Answer: B
Rationale: The correct answer is B: Deductive. Deductive reasoning starts with a general principle or theory and applies it to specific situations to draw conclusions. In this scenario, the nurse is using deductive reasoning by starting with the big picture (general principle) and anticipating specific findings (applying the principle to specific situations). Inductive reasoning (choice A) involves drawing general conclusions based on specific observations. Careful reasoning (choice C) and critical reasoning (choice D) are broad terms that do not specifically describe the type of logical reasoning being used in this context.
Question 3 of 5
The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is A: Dementia. Given the patient's age, history of falls, poor hygiene, weight loss, social isolation, and cognitive impairment, dementia is the most likely suspicion. The patient's cognitive decline may have contributed to the falls, poor self-care, and social isolation. Weight loss and cognitive decline following a significant life event (wife's death) are common in dementia. Delirium (C) is typically acute and reversible, not chronic like dementia. Elder abuse (B) may be a concern but is not the most likely cause based on the information provided. Alcohol abuse (D) is not supported by the patient's history and presentation.
Question 4 of 5
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
Correct Answer: C
Rationale: The correct answer is C because asymmetrical chest expansion indicates a potential complication such as pneumothorax, a common complication of mechanical ventilation in ARDS. This can lead to decreased lung compliance and oxygenation. A: Urine output may indicate renal function but is not directly related to ventilator complications. B: Pulse oximeter reading greater than 95% indicates good oxygenation, which is a positive finding. D: Sinus tachycardia can be due to various reasons and is not specific to ventilator complications.
Question 5 of 5
The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior?
Correct Answer: D
Rationale: The correct answer is D because a change in respiratory rate from rapid to slow indicates impending respiratory failure. Initially, a rapid respiratory rate is a compensatory mechanism to maintain oxygenation. However, a shift to slow breathing suggests fatigue and impending respiratory arrest. A: Incorrect. Inability to breathe unless sitting upright is indicative of orthopnea, not necessarily respiratory fatigue leading to respiratory arrest. B: Incorrect. Using abdominal muscles during expiration is a normal breathing pattern and may not necessarily indicate impending respiratory arrest. C: Incorrect. An increased inspiratory-expiratory ratio may indicate respiratory distress but not specifically respiratory fatigue leading to respiratory arrest.