ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Lifting the client to the bed with assistance is not recommended during a seizure. Moving the client can increase the risk of injury to both the client and the nurse. The primary focus should be on ensuring the client's safety by preventing injury from nearby objects and allowing the seizure to run its course. Turning the client onto their back is not advisable during a seizure. This position can increase the risk of airway obstruction and aspiration. Instead, the client should be turned onto their side to maintain an open airway and allow any secretions to drain from the mouth, reducing the risk of aspiration. Clearing the nearby area of furniture is the most appropriate action. This helps to prevent the client from injuring themselves on hard or sharp objects during the seizure. Ensuring a safe environment is a key priority in managing a seizure, as it minimizes the risk of physical harm. Placing a tongue depressor in the client's mouth is an outdated and dangerous practice. It can cause injury to the client's teeth, mouth, or airway. There is also a risk of the client biting down and breaking the depressor, leading to choking hazards. Modern seizure management guidelines strongly advise against placing any objects in the client's mouth during a seizure.
Question 2 of 5
A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, 'I should start planning the trip that we want to take.' Which of the following ego-defense mechanisms is the client expressing?
Correct Answer: B
Rationale: Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner's condition. Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client's statement about planning a trip despite their partner's terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner's impending death. Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client's statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality. Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner's condition.
Question 3 of 5
A nurse is caring for a client who has a new diagnosis of insulin-dependent diabetes mellitus. The client states, 'I am concerned about being able to monitor my blood glucose regularly due to my busy schedule.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale: You should be fine as long as you check your blood glucose before eating.' This response is not ideal because it oversimplifies the complexity of managing insulin-dependent diabetes. Blood glucose monitoring should be done at various times throughout the day, including before meals, after meals, and possibly before bedtime, to ensure proper management and avoid complications. Limiting checks to just before meals may not provide a comprehensive picture of the client's glucose levels. 'We can discuss several scheduling options for monitoring your blood glucose.' This response is the most appropriate as it acknowledges the client's concern and offers a collaborative approach to finding a solution. It allows the nurse to tailor the blood glucose monitoring schedule to fit the client's busy lifestyle, ensuring better adherence and management of diabetes. This approach also empowers the client by involving them in their care plan. 'You should reorganize your schedule around your blood glucose monitoring.' While it is important for the client to prioritize their health, this response may come across as dismissive of the client's busy schedule. It does not offer practical solutions or flexibility, which are crucial for long-term adherence to diabetes management. A more supportive and collaborative approach would be more effective. 'Your provider will set up a schedule for when you should monitor your blood glucose.' This response places the responsibility solely on the healthcare provider and does not address the client's immediate concern about fitting blood glucose monitoring into their busy schedule. While the provider's input is important, the nurse should also offer immediate support and practical solutions. Collaborative planning is key to effective diabetes management.
Question 4 of 5
A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by their provider. Which of the following is an appropriate response by the nurse?
Correct Answer: D
Rationale: Asking the provider is cautious but less proactive; pushing prescribed meds dismisses autonomy; the FDA doesn’t fully regulate TCM. Arranging a referral respects the client’s choice and facilitates safe exploration.
Question 5 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.