ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
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 1 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: Hallucinations are typically associated with psychosis, where individuals experience sensory perceptions that are not real. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are hallmark features of mania, a state of elevated mood and energy often seen in bipolar disorder. These symptoms reflect the impulsivity, racing thoughts, and increased activity levels characteristic of manic episodes.
Therefore, the correct answer is A for psychosis and B, C, D, E for mania.
Extract:
Nurses' Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Client also reports urinary frequency and decreased fetal movement. Client is a G3 P2 with one preterm birth.
Vital Signs
Day 1, 0900:
Temperature (oral) 36.9°C (98.4°F)
Heart rate 72/min
Respiratory rate 16/min
BP 162/112 mm Hg
Oxygen saturation 97% on room air
Diagnostic Results
Day 1, 1000:
Appearance cloudy (clear)
Color yellow (yellow)
pH 5.9 (4.6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03)
Leukocyte esterase negative (negative)
Nitrites negative (negative)
Ketones negative (negative)
Crystals negative (negative)
Casts negative (negative)
Glucose trace (negative)
WBC 5 (0 to 4)
WBC casts none (none)
RBC 1 (less than or equal to 2)
RBC casts none (none)
Question 2 of 5
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
Correct Answer: A, B, C, F
Rationale:
Correct Answer: A, B, C, F
Rationale:
A: Urine protein indicates possible preeclampsia, a serious prenatal complication.
B: Decreased fetal activity can signal fetal distress or other issues.
C: Abnormal blood pressure levels may indicate gestational hypertension or preeclampsia.
F: Headaches can be a symptom of preeclampsia, requiring immediate attention to prevent complications.
Incorrect
Choices:
D: Urine ketones usually indicate dehydration or inadequate nutrition, not a prenatal complication.
E: Respiratory rate is not typically used to assess prenatal complications.
G: Gravida/parity information is important but does not directly indicate a prenatal complication.
Extract:
Question 3 of 5
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rubber-backed area rugs can prevent slipping and falling accidents, which is crucial for a postoperative hip replacement patient. It provides stability and reduces the risk of injuries.
Choice A is incorrect because wearing shoes at home can actually increase the risk of falls due to potential slipping hazards.
Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard.
Choice C is incorrect as marking the edges of the doorway with tape does not address the main safety concern of preventing falls related to the rugs.
By selecting choice D, the nurse addresses the specific safety need of the postoperative hip replacement patient and promotes a safer home environment.
Question 4 of 5
A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
Correct Answer: B
Rationale:
Correct Answer: B
Rationale:
1. Safety: The client with a prescription for compression stockings needs them for circulation and to prevent complications. Not receiving them could lead to health risks.
2. Nursing responsibility: The nurse is accountable for ensuring that prescribed treatments are provided, making it crucial for the AP to report this issue.
3. Collaboration: By reporting to the nurse, the AP allows for timely intervention to address the missed prescription, promoting client safety and well-being.
Summary of other choices:
A: Requesting assistance with the commode is a routine task that the AP can handle independently.
C: Sitting in a chair does not pose a significant risk or indicate a change in condition requiring immediate attention.
D: Consuming all food is a positive sign of appetite and does not warrant immediate reporting unless there are dietary restrictions or concerns documented.
Question 5 of 5
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious via airborne droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and healthcare workers. This isolation precaution is crucial in controlling the transmission of varicella. Administering aspirin (choice
B) is contraindicated in varicella due to the risk of Reye's syndrome. Using droplet precautions (choice
C) is not appropriate for varicella, as it is transmitted through airborne particles. Assessing for Koplik spots (choice
D) is related to measles, not varicella.