Questions 85

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ATI RN Test Bank

ATI Fundamental Exams Questions

Extract:


Question 1 of 5

What would be the primary focus of interventions for a client who sleepwalks?

Correct Answer: D

Rationale: Maintaining safety during sleepwalking episodes is the primary focus to prevent injuries. Medications, verbalizing feelings, and a quiet environment are secondary or unrelated to immediate safety concerns.

Question 2 of 5

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

Correct Answer: B

Rationale: Padding against bony prominences protects the skin. Two fingers should fit between the restraint and wrist, quick-release knots are used, and restraints are tied to the bed frame, not side rails.

Question 3 of 5

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer: C

Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with necrotic subcutaneous tissue, appearing as a deep crater. Exposed bone is stage 4, blood-filled blisters are earlier stages, and partial-thickness loss is stage 2.

Question 4 of 5

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain?

Correct Answer: B

Rationale: Elevated blood pressure is a common response to acute pain due to sympathetic nervous system activation. Pain typically increases respiratory and heart rates and dilates pupils, not the opposite.

Question 5 of 5

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

Correct Answer: A

Rationale: Painful dermatitis from radiation therapy is acute pain, resulting from recent tissue damage. Cancer pain relates to tumor effects, chronic pain persists longer, and neuropathic pain involves nerve damage.

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