ATI RN
ATI Msn De5320 Fundamentals Exam Questions
Extract:
Question 1 of 5
A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?
Correct Answer: C
Rationale: Multiple sclerosis causes muscle weakness, balance issues, and coordination problems, increasing fall risk. Inguinal hernia may cause discomfort, hyperlipidemia affects cholesterol, and hyperthyroidism may cause tremors, but none directly impact balance as significantly.
Question 2 of 5
A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Locking bed wheels ensures stability during transfer, enhancing safety. A 90° chair angle complicates movement, the chair should be on the strong side, and raising the bed excessively risks unsafe positioning.
Question 3 of 5
A nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?
Correct Answer: C
Rationale: Dilated pupils enhance vision during fight-or-flight, driven by adrenaline. Airways dilate, blood pressure rises, and glucose increases for energy, ruling out other options.
Question 4 of 5
A nurse is teaching a class about stress. The nurse should include that which of the following is a manifestation of prolonged stress?
Correct Answer: D
Rationale: Prolonged stress suppresses the immune system via chronic cortisol elevation, increasing infection risk. Anemia is unrelated, stress causes hyperglycemia, and blood pressure typically rises.
Question 5 of 5
The nurse identified that the patient has pain of 7 on a scale of 1 to 10 and he expresses discomfort over the incisional area. He guards the area by resisting movement. Which component is the S in a three-part nursing diagnostic statement using the PES format? Nursing Diagnosis: Acute pain r/t incisional trauma with guarding and restricted movement
Correct Answer: C
Rationale: In the PES format, ‘S’ (Signs/Symptoms) includes observable evidence like guarding and restricted movement. Acute pain is the problem, incisional trauma the etiology, and swelling is not mentioned.