ATI RN
ATI Nurs 2000 Fundamentals Questions
Extract:
Question 1 of 5
A nurse is reviewing a fall risk assessment for a client. Which of the following findings place the client at risk for a fall? Select all that apply.
Correct Answer: A,C,D
Rationale: An electrical cord on the floor over a walkway can pose a tripping hazard increasing the risk of falls. It's important to keep walkways clear of any obstacles to prevent falls. Using a cane to ambulate does not necessarily increase the risk of falls. In fact canes are often used to improve balance and stability reducing the risk of falls. However it's important that the cane is used correctly and is the right height for the individual. Unsecured throw rugs especially over a slippery surface like a tile floor can easily cause someone to slip and fall. It's recommended to secure rugs with non-slip backing or remove them entirely from high-traffic areas. Macular degeneration can lead to vision loss which can increase the risk of falls. Individuals with vision impairments may not be able to see hazards in their path making them more prone to falls.
Question 2 of 5
A nurse is assessing a patient who is in the active stage of dying. What are the signs and symptoms of impending death? (Select all that apply)
Correct Answer: A,C
Rationale: Mottling of the skin especially in the lower extremities is a common sign of impending death. This is due to decreased blood flow and can be a sign that the body is starting to shut down. This statement is incorrect. As a person nears death their blood pressure typically decreases not increases. Cheyne-Stokes breathing which is characterized by a pattern of increasing and decreasing respiration with periods of apnea is a common symptom in the final stages of life. This statement is incorrect. As a person nears death their skin may become cool to the touch and may appear pale or mottled. Regular respiration is not typically a sign of impending death. In fact changes in breathing patterns such as Cheyne-Stokes breathing are more common.
Question 3 of 5
A nurse is ordering equipment for a medical-surgical unit. Which of the following equipment should the nurse identify as being ergonomic? (Select all that apply)
Correct Answer: A,D
Rationale: Wrist supports for computer keyboards are considered ergonomic because they help maintain a neutral wrist position reducing the risk of repetitive strain injuries. IV stands at a fixed height are not considered ergonomic. Adjustable height stands would be more ergonomic as they can be tailored to the user's height reducing the risk of strain or injury. Standard height toilets are not considered ergonomic.
Toilets that are height-adjustable or at a comfortable height for the user would be more ergonomic reducing the risk of falls or strain. Shower chairs are considered ergonomic as they can reduce the risk of falls in the shower by providing a stable seat for users. They can be particularly beneficial for individuals with mobility issues.
Question 4 of 5
During a home visit to a hospice patient the patient states 'I used to love eating strawberry ice cream but with the dietary restrictions of my condition I have not been able to have ice cream in years.' How should the nurse respond?
Correct Answer: A
Rationale: This response shows empathy and understanding towards the patient's situation. It acknowledges the patient's craving for strawberry ice cream and offers a compromise that aligns with the patient's dietary restrictions. This response may come across as insensitive and dismissive of the patient's feelings. It's important to show empathy and understanding when dealing with patients especially those in hospice care. This response may not be appropriate as it does not consider the patient's dietary restrictions. While it shows empathy it's important to respect and adhere to the patient's dietary needs. This response may not be appropriate as it does not address the patient's statement. It's important to acknowledge and respond to the patient's feelings and concerns.
Question 5 of 5
A nurse is caring for a patient with moderate vision impairment. What actions should the nurse take?
Correct Answer: B
Rationale: While adequate lighting is important for people with vision impairment direct lighting from open window shades can create glare which can make vision problems worse. Facing the patient when speaking to them can help the patient use visual cues to better understand the conversation. Using gestures can be helpful for some patients with vision impairment but it may not be beneficial for a patient with moderate vision impairment who may not be able to see the gestures clearly. Speaking loudly is not necessary for a patient with vision impairment unless they also have a hearing impairment.