ATI RN
ATI Nurs 2000 Fundamentals Questions
Extract:
Question 1 of 5
A nurse enters a hospice patient’s room to perform an assessment after receiving the morning report.The outgoing nurse reports that the patient is showing loss of appetite, swelling of the limbs, increased sleep, CheyneStokes respirations, and hallucinations.Which of the following indicates the nurse understands the report?
Correct Answer: D
Rationale: Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting which focuses on providing comfort and quality of life for patients who are nearing the end of life rather than aggressive lifesaving interventions. Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting these symptoms are expected and are indicative of the natural dying process. The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea are often seen in patients nearing the end of life. They are not curative but are a sign of the body's decreasing metabolic demands and changing physiology as death approaches. The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described including loss of appetite swelling of the limbs increased sleep Cheyne-Stokes respirations and hallucinations are all common in the final stages of life. Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.
Question 2 of 5
A patient arrives in the emergency department exhibiting symptoms of a cerebrovascular accident (CVA). Which diagnostic evaluations would the nurse anticipate before treatment is initiated?
Correct Answer: B
Rationale: While prothrombin level is an important test in evaluating blood clotting disorders it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CV
A) or stroke. Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain an ischemic stroke a tumor or other conditions. A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart. A lumbar puncture or spinal tap may be used in some cases to help diagnose a CVA but it is not typically part of the initial diagnostic evaluations.
Question 3 of 5
A nurse is conducting a mobility assessment on a patient. The patient can stand up from a seated position using a cane for support. Which of the following activity levels should the nurse assign to the patient?
Correct Answer: C
Rationale: Minimal assistance implies that the patient needs some help but can do most of the task on their own. In this case the patient is able to stand up from a seated position using a cane for support which suggests that they do not need assistance. Moderate assistance implies that the patient needs more help to perform the task. The patient in the scenario is able to perform the task independently with the help of a cane. No assistance means that the patient can perform the task independently. This is the most fitting answer because the patient is able to stand up from a seated position using a cane for support. Maximum assistance implies that the patient is unable to perform the task without substantial help. This does not apply to the patient in the scenario as they are able to stand up independently with the help of a cane.
Question 4 of 5
A nurse is teaching a patient about reducing the risk for falls. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Installing handrails in the bathroom is a recommended strategy for reducing the risk of falls. Handrails provide support and stability particularly in slippery environments like the bathroom. Using a standard height toilet seat is not necessarily a recommended strategy for reducing the risk of falls. A toilet seat at an appropriate height for the individual would be more beneficial. Wearing backless shoes is not a recommended strategy for reducing the risk of falls. Shoes with good support and non-slip soles are typically recommended. Covering extension cords with a throw rug is not a recommended strategy for reducing the risk of falls. This could potentially create a tripping hazard.
Question 5 of 5
A nurse is teaching a class about physiological changes to hearing in older adult patients. Which of the following should the nurse include?
Correct Answer: C
Rationale: While the thickness of the tympanic membranes can indeed change with age it typically increases rather than decreases. Thickening of the tympanic membranes can contribute to hearing loss by reducing the ability of the ear to transmit sound vibrations. Tinnitus or ringing in the ears is not typically decreased in older adults. In fact tinnitus is often more common in older individuals and can be a sign of age-related hearing loss. A decreased ability to hear high-frequency sounds is a common physiological change associated with aging. This is often one of the first signs of age-related hearing loss. Decreased ear wax is not typically associated with aging. In fact some older adults may produce more ear wax which can contribute to hearing problems if it becomes impacted.