ATI RN
ATI RN Custom Exams Set 5
1. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?
- A. The client who needs both sequential compression devices removed
- B. The elderly woman who needs assistance ambulating to the bathroom
- C. The surgical client who needs help changing the gown after bathing
- D. The male client who needs the intravenous fluid discontinued
Correct answer: A
Rationale: The correct answer is A. Removing sequential compression devices could increase the risk of thromboembolism, which is a serious complication. Therefore, this client should be seen first to prevent any potential harm. Choice B may be important, but it does not pose an immediate risk compared to thromboembolism. Choice C is a routine care task that can be delayed, and Choice D, discontinuing intravenous fluid, is important but not as urgent as preventing thromboembolism.
2. Which endocrine disorder would the nurse assess for in a client who has a closed head injury with increased intracranial pressure?
- A. Pheochromocytoma
- B. Diabetes insipidus
- C. Hashimoto’s disease
- D. Gynecomastia
Correct answer: B
Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (choice A) is a tumor of the adrenal gland and is not directly related to closed head injury or increased intracranial pressure. Hashimoto’s disease (choice C) is an autoimmune disorder affecting the thyroid gland, not commonly associated with head injuries. Gynecomastia (choice D) is the development of breast tissue in males and is not an endocrine disorder typically linked to closed head injuries.
3. Who is the first individual in the combat health support chain to make medically substantiated decisions based on military occupational specialty-specific medical training?
- A. Physician
- B. Physician assistant
- C. Combat medic
- D. Combat lifesaver
Correct answer: B
Rationale: The correct answer is 'Physician assistant.' Physician assistants are trained to make medically substantiated decisions based on their specific medical training within the combat health support chain. Choice A, 'Physician,' is incorrect as they may be involved but are not typically the first in line for such decisions as physician assistants. Choice C, 'Combat medic,' is incorrect as they usually provide immediate medical care but may not be the first to make medically substantiated decisions. Choice D, 'Combat lifesaver,' is incorrect as they are trained to provide basic life-saving interventions but may not have the specialized medical training to make complex medical decisions.
4. Identifying the strengths and weaknesses in the plan of nursing care is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: A
Rationale: The correct answer is A: Evaluation. Evaluation in nursing care involves assessing the effectiveness of the care plan, identifying strengths, weaknesses, and areas for improvement. This step helps ensure that the patient's needs are being met appropriately. Planning (choice B) involves developing the care plan based on the assessment data. Implementation (choice C) is the step where the care plan is put into action. Assessment (choice D) is the initial step in the nursing process that involves collecting and analyzing data about the patient's health status.
5. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?
- A. Preoccupation with calories
- B. Thick body hair
- C. Sore tongue
- D. Dry, brittle hair
Correct answer: D
Rationale: Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. In anorexia nervosa, the body lacks essential nutrients due to severe calorie restriction, leading to dryness and brittleness of the hair. Choices A, B, and C are less likely to directly indicate anorexia nervosa. Preoccupation with calories can be a behavioral symptom, thick body hair is not a typical finding associated with anorexia nervosa, and a sore tongue is more commonly related to nutritional deficiencies like vitamin deficiencies rather than anorexia nervosa.
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