ATI RN
ATI Custom T1 PM Summer 2023 Exam 5 Questions
Extract:
Question 1 of 5
A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?
Correct Answer: C
Rationale:
Correct Answer: C - The client grimaces when they move.
Rationale:
1. Grimacing is a physical expression that can be observed by the nurse.
2. It is an objective indicator, not influenced by individual interpretation.
3. Grimacing indicates non-verbal signs of pain, enhancing assessment accuracy.
Summary:
A. Reporting a burning sensation is subjective, based on client's perception.
B. Locating pain in the abdomen is subjective and lacks direct observation.
D. Rating pain on a scale is subjective, influenced by personal pain tolerance.
Question 2 of 5
A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
Correct Answer: D
Rationale: The correct answer is D because supporting a client's wishes to refuse prescribed treatments upholds the ethical principle of autonomy, which respects a person's right to make their own decisions about their care. This demonstrates the nurse's commitment to promoting the client's self-determination and independence. Describing medication side effects (
A) is important but doesn't directly relate to autonomy. Spending extra time to calm an agitated client (
B) is more about providing therapeutic communication and support. Ensuring client understanding of group participation expectations (
C) is about fostering informed consent.
Question 3 of 5
A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?
Correct Answer: B
Rationale: The correct answer is B: Minimize skin exposure to moisture. Moisture can lead to skin breakdown, especially in clients with limited mobility. Keeping the skin dry helps prevent breakdown. Turning the client every 4 hours (
A) helps with pressure relief but does not specifically address moisture. Massaging erythematous bony prominences (
C) can cause further damage to fragile skin. Environmental humidity less than 30% (
D) is not directly related to skin breakdown. Using pillows to keep heels off the bed surface (E) helps with pressure redistribution but does not address moisture.
Question 4 of 5
A nurse is assisting with teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D: Nonmaleficence. Nonmaleficence is the ethical principle of "do no harm." In healthcare, it means that the primary goal is to avoid causing harm to the patient. By working to not cause harm to a client while trying to achieve the best possible outcome, the nurse is adhering to the principle of nonmaleficence.
Why the other choices are incorrect:
A: Kindness - While kindness is important in nursing practice, it is not specifically related to the ethical principle of nonmaleficence.
B: Good manners - Good manners are about politeness and etiquette, not directly related to the ethical principle of nonmaleficence.
C: Common courtesy - Common courtesy is about being polite and considerate, but it does not encompass the ethical principle of nonmaleficence.
Question 5 of 5
A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?
Correct Answer: B
Rationale: The correct answer is B: Tugging on the affected ear lobe. In otitis media, infants may tug or rub the affected ear due to pain or discomfort. This behavior is a common sign of ear discomfort in infants. Erythema and edema of the affected auricle (choice
A) may be seen in external ear infections, not otitis media. Bluish-green discharge from the ear canal (choice
C) is not a typical finding in otitis media. An increase in appetite (choice
D) is not a common symptom of otitis media. Thus, choice B is the most appropriate finding in an infant with otitis media.