ATI RN
ATI Nursing 4650 Comprehensive Exam Questions
Extract:
Question 1 of 5
The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?
Correct Answer: A
Rationale: The client's flinching when the nurse palpates his abdomen suggests that he may be experiencing pain. Pain can cause behavioral changes in older adults, including withdrawal, decreased verbal communication, and altered facial expressions. The client's inability to verbally communicate but ability to nod and smile in response to questions further supports the possibility of pain affecting his behavior.
Question 2 of 5
A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: Holding the dropper approximately 2 cm (1 in) above the nares allows for precise instillation of the drops into the nasal passages without touching the dropper to the nares, which helps prevent contamination.
Question 3 of 5
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?
Correct Answer: C
Rationale: Haloperidol can prolong the QT interval, potentially causing dysrhythmias like torsade de pointes. Monitoring for signs such as palpitations or syncope is critical.
Question 4 of 5
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: Applying ice to the affected area is a common postoperative instruction following knee surgery. Ice helps reduce swelling, inflammation, and pain. It is usually recommended for short intervals, such as 20 minutes every few hours, for the first 48 to 72 hours after surgery.
Question 5 of 5
A nurse is caring for a client who has named a person to serve as his health care proxy. The client talks about this type of advance directives. Which of the following statements by the client indicates a need for clarification?
Correct Answer: B
Rationale: The client does not have to choose a family member as their health care proxy; they can select any trusted individual. This statement requires clarification to ensure the client understands their autonomy in choosing a proxy.