ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
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 2 of 5
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 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: 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.
Extract:
Graphic Record
Admission weight 74.8 kg (165 lb)
Current weight 74.38 kg (164 lb)
Provider Prescriptions
Lisinopril 10 mg daily
Lithium 600 mg BID
Omeprazole 40 mg daily
I&O
Prior Day Intake and Output
0800:
Intake 30 mL orange juice
Output 800 mL clear urine
1200:
Intake 60 ml water with lunch
Output 300 ml clear urine
1800
Intake 120 ml. water with dinner
Output 500 mL clear urine
2100:
Intake 30 ml dark soda
Output 200 ml. clear urine
Nurses Notes
0800:
A client who has bipolar disorder is admitted to the inpatient psychiatric unit. During the morning assessment, the client reports blurred vision and an increase in urine output. It is noted that the client is having clonic jerking of upper extremities. Provider notified and laboratory tests ordered. Skin is warm and dry without rash.
Laboratory Results
0900:
Creatinine 0.9 mg/dL (0.5 to 1.1 mg/dL)
Lithium level 2.5 mEq/L (0.6 to 1.2 mEq/L)
Fasting blood glucose 80 mg/dL (74 to 106 mg/dL)
Urinalysis:
Appearance: clear (clear)
Color: faint yellow (amber yellow)
Specific gravity 1.32 (adult client 1.01 to 1.025)
Nitrites: none (none)
Ketones: none (none)
Bilirubin: none (none)
Question 4 of 5
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (
B), cardiac dysrhythmias (
C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
Extract:
Question 5 of 5
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.