ATI RN
ATI RN Fundamentals 2023 II Questions
Extract:
Question 1 of 5
A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?
Correct Answer: C
Rationale: The correct answer is C: Place an activated tuning fork in the middle of the client's forehead. This is the appropriate action for the Weber's test because it helps assess for asymmetrical hearing loss. Placing the tuning fork on the forehead allows sound to be conducted through bone, bypassing the outer and middle ear. If the client hears the sound more in one ear than the other, it indicates conductive hearing loss in the ear that hears it less. Whispering words (
B) and delivering high-pitched sounds (
A) are not part of the Weber's test. Holding the tuning fork against the mastoid process (
D) is part of the Rinne test, not the Weber's test.
Question 2 of 5
A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?
Correct Answer: D
Rationale: The correct answer is D: Offer to play music in the client's room. Music therapy has been shown to effectively reduce pain perception and promote relaxation. It can distract the client from the pain and enhance their overall well-being. Massaging the sacrum (choice
A) may worsen the pressure injury and should be avoided. Bright lights (choice
B) may exacerbate the client's discomfort. Loosening bed linens (choice
C) may not directly address the pain issue.
Therefore, providing music therapy is the most appropriate nonpharmacological intervention in this scenario.
Question 3 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale:
Correct Answer: A. "Have you thought about harming yourself?"
Rationale: This response is crucial in assessing the client's risk of suicide. It shows the nurse's immediate concern for the client's safety and opens a dialogue to understand the severity of the client's suicidal ideation. By directly addressing the client's statement about wanting to die, the nurse can determine the level of risk and take appropriate actions to ensure the client's safety.
Incorrect
Choices:
B: "Tell me more about your partner." - This response does not address the immediate concern of suicidal ideation and misses the opportunity to assess the client's safety.
C: "You should discuss these feelings with your provider." - While important, this response does not address the urgent need to assess the client's risk of harm to self.
D: "Why did you stop taking your medication?" - While medication adherence is important, the client's statement about wanting to die takes precedence in this situation.
Question 4 of 5
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?
Correct Answer: B
Rationale: The correct answer is B because when a client believes that their needs will be met through education, they are more likely to be motivated to learn. This belief creates a sense of purpose and relevance, driving the client to engage in the learning process.
Explanation of other options:
A: While it's important for the nurse to explain the need for education, this may not directly increase the client's motivation if they don't see the relevance to their needs.
C: Seeking family approval may provide external motivation but may not necessarily lead to intrinsic motivation for learning.
D: Nurse empathy is important for building rapport but may not be the primary factor in increasing motivation to learn.
Question 5 of 5
A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Provide the client with a night light. This is important for fall prevention as it helps the client see the surroundings during the night, reducing the risk of tripping or falling. A: Keeping the room temperature low can increase the risk of falls due to discomfort. B: Placing the table far from the bed can make it difficult for the client to reach items and increase the risk of falls. D: Elevating full-length side rails can lead to entrapment and should only be used when necessary and with proper assessment.