ATI LPN Critical Thinking Exam

Extract:

Patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated

Question 1 of 5

The nurse documents in the patient record, '0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.' The most significant statement about the documentation is that it is:

A. unacceptable because it is vague subjective data without supportive dataB. good because it shows immediate response to the problemC. inadequate because the time of physician notification is not listedD. acceptable because it includes assessment, intervention and evaluation

Correct Answer: D

Rationale: The documentation (
D) includes assessment (pain, vital signs), intervention (analgesic), and evaluation (relief), making it complete. A, B, and C overlook its comprehensive nature.

Extract:

Question 2 of 5

When using the SOAP method of charting, S stands for subjective data which means:

A. patient provided dataB. all of the answers are correctC. observed dataD. measured data

Correct Answer: A

Rationale: Subjective data (
A) includes patient-reported information like pain or symptoms. Observed (
C) and measured (
D) data are objective, and B is incorrect as only A is accurate.

Question 3 of 5

Patient health care records are:

A. not used by anyone else but the direct care providersB. concise, legal records of all care given and responsesC. owned by the patient, who has a right to see the data any time he/she wishesD. confidential information and cannot be taken to court

Correct Answer: B

Rationale: Records (
B) are legal, concise documentation of care and responses, used by multiple parties. A, C, and D are incorrect regarding usage, ownership, and legal status.

Extract:

Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation

Question 4 of 5

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

A. signs of fluid overloadB. symptomsC. data clusteringD. urinary retention

Correct Answer: C

Rationale: Grouping signs like flushed skin and fever (
C) is data clustering, suggesting dehydration or infection. Fluid overload (
A) shows edema, symptoms (
B) are subjective, and urinary retention (
D) involves bladder issues.

Extract:

Patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg

Question 5 of 5

Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

A. painB. skin integrityC. fluid volumeD. knowledge deficit

Correct Answer: A

Rationale: Pain (
A) is the immediate need due to severe discomfort, requiring urgent management. Skin integrity (
B), fluid volume (
C), and knowledge deficit (
D) are secondary.

ATI LPN Critical Thinking Exam | Nurselytic

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