ATI RN
ATI Nurs 2000 Fundamentals Questions
Extract:
Question 1 of 5
Nurse's note: Client body position slumped forward in chair with head on bedside table and no eye contact. Client slow to verbally respond to Questions. Vital signs noted no change in condition at this time. Denies any pain or discomfort at this time. Requesting to speak to a chaplain at this time. Which are included in the 5 stages of grief? (Select all that apply)
Correct Answer: B,C,D,E
Rationale: Repentance is not typically included in the five stages of grief as outlined by psychiatrist Elisabeth Kübler-Ross. Bargaining is one of the five stages of grief. It often involves the individual making deals or promises to a higher power in an attempt to reverse or lessen the loss. Depression is a stage of grief where the individual may experience intense feelings of sadness hopelessness and despair. Acceptance is the final stage of grief where the individual begins to accept the reality of their loss. Anger is a stage of grief where the individual may feel intense anger towards the situation themselves or others.
Question 2 of 5
A nurse is caring for a patient who states 'I did not take my medication because my partner forgot to remind me.' The nurse should identify that the patient is demonstrating which of the following defense mechanisms?
Correct Answer: C
Rationale: Regression is a defense mechanism where an individual reverts to an earlier stage of development or a less mature behavior when faced with stress or anxiety. This does not fit the scenario provided. Projection involves attributing one's own unacceptable feelings or thoughts to others. This is not the case in the scenario provided. Rationalization involves creating logical but untrue explanations to justify unacceptable behavior or feelings. In this scenario the patient is rationalizing their failure to take their medication by blaming their partner's forgetfulness. Repression involves unconsciously blocking out painful or uncomfortable thoughts or feelings. This does not fit the scenario provided.
Question 3 of 5
The provider orders fluid replacement for a dehydrated patient. The order entered is 1000 mL over 10 hours. If using an IV pump what is the rate that the nurse should enter?
Correct Answer: A
Rationale:
Step 1 is to calculate the rate of fluid replacement. The formula for this is: Rate (mL/hr) =
Total volume (mL) ÷ Time (hr) So for this question: Rate (mL/hr) = 1000 mL ÷ 10 hr = 100 mL/hr.
Question 4 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 5 of 5
A nurse is teaching a patient about reducing the risk for falls. Which of the following statements should the nurse make?
Correct Answer: A
Rationale: Installing handrails in the bathroom is a recommended strategy for reducing the risk of falls. Handrails provide support and stability particularly in slippery environments like the bathroom. Using a standard height toilet seat is not necessarily a recommended strategy for reducing the risk of falls. A toilet seat at an appropriate height for the individual would be more beneficial. Wearing backless shoes is not a recommended strategy for reducing the risk of falls. Shoes with good support and non-slip soles are typically recommended. Covering extension cords with a throw rug is not a recommended strategy for reducing the risk of falls. This could potentially create a tripping hazard.