ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates empathy and encourages the client to express their feelings, fostering open communication. By understanding the client's concerns, the nurse can address them effectively, promoting a sense of control and dignity for the client.
Option B is incorrect as it disregards the client's request to not use the bed pan. Option C is incorrect as it assumes the client can be ambulated to the bathroom, which may not be feasible. Option D is incorrect as it is authoritarian and dismisses the client's autonomy. It is essential to prioritize the client's comfort and emotional well-being in end-of-life care.
Question 2 of 5
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
Correct Answer: D
Rationale: The correct answer is D: "Are you thinking about ending your life?" This question is crucial as it directly addresses the client's statement about finding it hard to go on without their child, indicating potential suicidal ideation. By asking this question first, the nurse can assess the client's risk of harm and provide appropriate interventions if necessary.
Option A: "What has helped you through difficult times in the past?" - While this is a supportive question, it does not address the immediate concern of suicidal ideation.
Option B: "Has anyone in your family committed suicide?" - This question may be relevant but is not as urgent as directly asking about the client's current thoughts of ending their own life.
Option C: "Is there anyone you would like involved in your care?" - This question focuses more on the client's support system rather than addressing the potential risk of harm.
In summary, asking about suicidal thoughts first is crucial in ensuring the client's safety and well-being in this scenario.
Extract:
Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with cleaning the house and hosting parties. At times the client is overly joyous and has a very elevated sense of self-confidence. The adult child states that the client has also demonstrated very impulsive spending habits and expresses concern about the client giving away large sums of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following them around inside and outside the house for days. Client asks the person what they want but never receives an answer. Client states that this person has never told them to do anything; they just stare and smile
Question 3 of 5
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: Hallucinations are typically associated with psychosis, where individuals experience sensory perceptions that are not real. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are hallmark features of mania, a state of elevated mood and energy often seen in bipolar disorder. These symptoms reflect the impulsivity, racing thoughts, and increased activity levels characteristic of manic episodes.
Therefore, the correct answer is A for psychosis and B, C, D, E for mania.
Extract:
Question 4 of 5
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial to ensure the child's comfort and promote healing. Scheduled administration of analgesics helps maintain a consistent level of pain control, preventing the child from experiencing severe pain. This approach also helps in preventing the need for rescue doses when the pain becomes unbearable. Applying a warm compress (choice
A) may not be appropriate as it can increase the risk of infection at the operative site. Giving cromolyn nebulized solution (choice
C) is not indicated for postoperative pain management following appendicitis surgery. Offering clear liquids (choice
D) 6 hr post-surgery may not be recommended until the child has shown signs of bowel function recovery.
Question 5 of 5
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms like shuffling gait, which is a serious adverse effect requiring immediate medical attention to prevent further complications. A: Weight gain is a common side effect but not urgent. B: Dry mouth is a common side effect that can be managed with oral hygiene. D: Sedation is a common side effect that may resolve over time.