ATI RN
ATI RN Fundamentals 2023 Exam 5 Questions
Extract:
Question 1 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 2 of 5
A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
Correct Answer: A
Rationale: Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell's palsy or a stroke. The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve.
Therefore, this response is not relevant to the assessment of cranial nerve VII. Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve. Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.
Question 3 of 5
A charge nurse is teaching a group of nurses about decreasing the risk for catheter-associated urinary tract infections in clients. Which of the following information should the nurse include in the teaching?
Correct Answer: D
Rationale: Larger catheters (20 French) increase trauma risk; full bags risk backflow; disconnecting breaks sterility. Keeping the bag below bladder level prevents urine backflow, reducing infection risk.
Question 4 of 5
A nurse is teaching a class about the levels of health care services. The nurse should include that emergency care is part of which of the following health care services?
Correct Answer: D
Rationale: Preventive care focuses on disease prevention, not emergency treatment. Tertiary care involves specialized, long-term treatments, not immediate care. Primary care is the first point of contact for general health, not emergencies. Secondary care includes emergency care, providing specialized, urgent treatment after referral or direct access.
Question 5 of 5
A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?
Correct Answer: B
Rationale: Bounding pulses are typically associated with increased cardiac output or high blood pressure, rather than active bleeding. In the context of postoperative care, bounding pulses might indicate fluid overload or other cardiovascular issues, but they are not a primary sign of active bleeding. Restlessness is a common sign of hypovolemia, which can occur due to active bleeding. When a patient is losing blood, their body may respond with anxiety or restlessness as a result of decreased oxygen delivery to tissues and organs. This is a compensatory mechanism to maintain perfusion. Restlessness, along with other signs such as tachycardia and hypotension, can indicate significant blood loss and the need for immediate intervention. Warm skin is generally not associated with active bleeding. In fact, patients who are actively bleeding may present with cool, clammy skin due to peripheral vasoconstriction as the body attempts to maintain core temperature and blood flow to vital organs. Warm skin might be observed in other conditions, such as fever or inflammation, but it is not a typical sign of active bleeding. Brisk capillary refill, which is a capillary refill time of less than 2 seconds, indicates good peripheral perfusion and is not a sign of active bleeding. In contrast, a delayed capillary refill time (greater than 2 seconds) can be a sign of poor perfusion, which might occur in the case of significant blood loss.
Therefore, brisk capillary refill is not indicative of active bleeding.