ATI RN
ATI Nurs 2000 Fundamentals Questions
Extract:
Question 1 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: B
Rationale: Hypoglycemia or low blood sugar is not typically a manifestation of the fight-or-flight response. In fact the opposite is true. During the fight-or-flight response the body's glucose levels often increase to provide extra energy for the perceived threat. Dilated pupils are a common physical manifestation of the fight-or-flight response. This physiological change allows more light to enter the eyes enhancing vision and awareness of the environment during a stressful event. Bronchial airway constriction is not typically associated with the fight-or-flight response. In fact the bronchial airways often dilate during this response to allow for increased oxygen flow which is necessary for physical exertion. Decreased blood pressure is not a typical response to stress. During the fight-or-flight response blood pressure usually increases to enhance blood flow to the muscles and brain.
Question 2 of 5
Select physical signs you may see in a patient who is actively dying.
Correct Answer: A,C,D
Rationale: Slow capillary refill is a sign that the body is not circulating blood as effectively as it should be. This can be a sign that a person is actively dying. Ringing in the ears also known as tinnitus is not typically a sign that a person is actively dying. It can be caused by a variety of factors including exposure to loud noise certain medications and some health conditions. Cold hands and feet can be a sign that a person is actively dying. As the body's systems start to shut down blood flow to the extremities can decrease causing them to feel cold. Mottled and blotchy skin especially on the hands feet and knees can be a sign that a person is actively dying. This is caused by reduced blood flow to the skin.
Question 3 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.
Question 4 of 5
A hospice nurse is caring for a patient who has terminal cancer and is receiving hospice care for stage 4 metastatic breast cancer. The patient experiences excruciating pain and is scheduled for morphine 10 mg IM every 6 hours. The patient is sleeping and the medication is due. What action should the nurse take?
Correct Answer: B
Rationale: Holding the pain medication until the patient wakes up is not the best choice. Pain can disrupt sleep and it's important to keep the patient as comfortable as possible. If the patient is sleeping it may be because the pain is well-controlled and delaying the medication could lead to a return of pain. The patient should be given the scheduled pain medication. This is the best choice because it ensures that the patient's pain is managed effectively. Even if the patient is sleeping the medication should be given to prevent the pain from returning. Calling the family and asking if the patient would like to be woken up to have their pain medication is not the best choice. The nurse should make this decision based on the patient's pain level and the medication schedule not on the family's preferences. The statement that the patient has become addicted to the medication and is sleeping the last dose off is not accurate. Addiction is a complex condition characterized by compulsive drug use despite harmful consequences. In this case the patient is receiving the medication for a legitimate medical reason and there is no indication of addiction.
Question 5 of 5
A nurse is setting goals for a patient who has Stage 4 Breast cancer is in hospice care and is at the end of life. Which of the following are realistic goals?
Correct Answer: B
Rationale: Increasing attendance at community social activities may not be a realistic goal for a patient in hospice care with Stage 4 breast cancer. The patient's physical condition and energy levels may limit their ability to participate in such activities. Receiving medication to minimize episodes of breakthrough pain is a realistic and important goal for a patient in hospice care. Effective pain management is a key aspect of end-of-life care. Experiencing a weight gain of one to two pounds per week may not be a realistic goal for a patient in hospice care with Stage 4 breast cancer. Patients at this stage of illness often experience weight loss not gain. Verbalizing an understanding of the mode of disease transmission may not be a relevant goal for a patient in hospice care with Stage 4 breast cancer. The focus of care at this stage is typically on comfort and quality of life rather than disease education.