ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Nurses: Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, 'I am an assistant to a powerful spirit.' Client is poorly groomed and has body odor.
0900:
Called to the client's room. Client states, 'I cannot believe you put me in a room with spiders on the wall,' Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states that they have diagnosed the client with schizophrenia. Client is to be started on medication and milieu therapy.
Laboratory Results
0700:
Urine drug screen: negative (negative)
History and Physical
0700:
Majority of client's history is obtained from client's parent who presents with client today. According to the parent, client has been acting strangely for a few months. Client's symptoms have been progressively worsening
In the last month, the client has been seeing things that are not present and believes that they are in a close relationship with 'a powerful spirit.' Client has not been bathing regularly for the last few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or drink alcohol. Client's grandparent has a history of schizophrenia.
Vital Signs
0730:
Heart rate 68/min
Respiratory rate 18/min
BP 118/81 mm Hg
Temperature 37.2°C (98.9°F)
Question 1 of 5
For each potential action, click to specify if the action is indicated or contraindicated for the client.
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: The correct answer is B, C, D indicated; A, E contraindicated.
- B: Asking the client about the content of their hallucinations is indicated as it helps assess their mental state.
- C: Instructing the client on expected hygiene practices is indicated for their overall well-being.
- D: Assessing the client for suicidal ideation is crucial for identifying any potential risk.
- A: Allowing the client to watch TV at a high volume can exacerbate hallucinations, so it is contraindicated.
- E: Placing the client in a room near the activity room may increase sensory stimulation, worsening their condition, so it is contraindicated.
Extract:
Question 2 of 5
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps the nurse understand the dynamics within the family, identify strengths and weaknesses, and assess how each member is coping with the loss. By determining roles, the nurse can tailor interventions to address specific needs and promote effective communication and support. Referring the family to a grief support group (
A) may be helpful later, but understanding the family dynamics comes first. Encouraging tasks assignment (
C) and establishing a routine (
D) are important, but understanding roles is foundational for effective intervention.
Question 3 of 5
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale:
Correct Answer: C - Keep the client on NPO status
Rationale: In acute appendicitis, the client may require urgent surgery to remove the inflamed appendix. Keeping the client NPO (nothing by mouth) is essential to avoid potential complications during surgery, such as aspiration of stomach contents. This action also helps prevent delays in the surgical intervention and minimizes the risk of infection.
Incorrect
Choices:
A: Placing the client's head of bed flat can increase intra-abdominal pressure and worsen the client's condition.
B: Applying heat to the client's abdomen can exacerbate inflammation and may mask the symptoms, delaying appropriate treatment.
D: Administering a laxative can be dangerous as it may cause the appendix to rupture due to increased pressure from fecal matter.
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 4 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:
Question 5 of 5
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used for ADHD, can cause liver injury. Monitoring liver function tests helps detect any abnormalities early. B, kidney function tests, are not directly affected by atomoxetine. C, hemoglobin and hematocrit, are not typically monitored for this medication. D, serum sodium and potassium, are not specific to atomoxetine. E, F, G are not provided.