ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 4
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Keep visitors at least 6 feet (1.8 m) away from the client. This is important in brachytherapy as the client is emitting radiation. By keeping visitors at a safe distance, the nurse ensures their safety from radiation exposure. A: Discarding the radioactive source in the trash can is incorrect as it poses a risk to others. B: Placing soiled linens in a biohazard bag is not directly related to radiation safety. C: Wearing an isolation gown does not provide sufficient protection against radiation.
Therefore, it is important for the nurse to maintain distance to prevent radiation exposure to visitors.
Question 2 of 4
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take.
Correct Answer: B, A, C, D
Rationale: The correct sequence of steps for the nurse to take in case of a small fire in the client's bathroom is as follows:
1. B: Activate the facility's fire alarm system - This is the first step to alert everyone in the facility and ensure a prompt response from the fire department.
2. A: Transport the client to another area of the nursing unit - Ensures the client's safety away from the fire hazard.
3. C: Close all nearby windows and doors - Helps contain the fire and prevent it from spreading further.
4. D: Use the unit's fire extinguisher to attempt to put out the fire - Only after ensuring the client's safety and containing the fire should the nurse attempt to extinguish it.
Other choices are incorrect because:
- A: Transporting the client should only be done after activating the fire alarm system to ensure a timely response.
- C: Closing windows and doors is important but should be done after alerting others about the fire
Question 3 of 4
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (
A) can be beneficial but is not as urgent. Providing transportation resources (
C) and choosing a home physical therapy agency (
D) are important but do not address the immediate safety concern of potential falls.
Extract:
History and Physical
Day 1, 0900:
A 52-year-old client brought to the emergency department by an adult child. The client is alert and oriented to person and time but does not know where they are. No history of substance use according to the client's adult child. The client exhibits constant movements and poor concentration. Hair and clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.
Vital Signs
Day 1, 0905:
Temperature 37.1°C (98.8°F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air
Question 4 of 4
The nurse is assessing the client. Select the 4 findings that require immediate follow-up
Correct Answer: A, B, D, E
Rationale: The correct answers are A, B, D, E. Hallucinations may indicate a serious mental health issue needing immediate attention. Heart rate abnormalities can signify cardiovascular problems. Skin turgor changes could indicate dehydration. Poor hygiene may suggest neglect or underlying health issues. Sleep pattern changes and personal grooming are important, but not typically requiring immediate follow-up.
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 5 of 4
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: The correct answer is A: Psychosis; B, C, D, E: Mania. Hallucinations are typically associated with psychosis due to perceptual disturbances. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all characteristic features of mania, which is a key symptom of Bipolar Disorder. Mania involves elevated mood, increased energy levels, impulsivity, and risky behavior, such as excessive spending. Disorganized thought process and pressured speech are manifestations of the racing thoughts and flight of ideas seen in mania. In summary, while hallucinations are consistent with psychosis, the other findings (lack of sleep, excessive spending habits, disorganized thought process, pressured speech) are more indicative of mania due to the presence of manic symptoms.