ATI LPN
ATI PN Comprehensive Predictor
1. When managing a physically assaultive client, the nurse's INITIAL priority is to
- A. Restrict the client to the room
- B. Place the client under one-to-one supervision
- C. Restore the client's self-control and prevent further loss of control
- D. Clear the immediate area of other clients to prevent harm
Correct answer: C
Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.
2. A client with acute diverticulitis is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the instructions?
- A. I will avoid eating fiber until this condition resolves
- B. I will take a laxative daily
- C. I will receive the nutrients I need through my IV fluids
- D. I will eat only solid foods
Correct answer: A
Rationale: The correct answer is A. During acute diverticulitis, avoiding fiber is essential as it helps reduce irritation of the intestines. Choice B is incorrect because taking a laxative daily can exacerbate diverticulitis. Choice C is incorrect as IV fluids mainly provide hydration and electrolytes, not all essential nutrients. Choice D is incorrect because during acute diverticulitis, a low-fiber or liquid diet is typically recommended to rest the bowel.
3. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?
- A. Apply counter-pressure for back pain
- B. Use deep breathing exercises
- C. Visualize the baby's head
- D. Use massage therapy
Correct answer: A
Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.
4. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?
- A. The client is experiencing an adverse reaction to rifampin.
- B. The client's seizure disorder is no longer under control.
- C. The client is showing evidence of phenytoin toxicity.
- D. The client is having adverse effects due to combination antimicrobial therapy.
Correct answer: C
Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.
5. What are the key components of a neurological assessment?
- A. Assess level of consciousness and motor function
- B. Check for headache and nausea
- C. Monitor reflexes and pupil size
- D. Assess for tremors and confusion
Correct answer: A
Rationale: The correct answer is A. A neurological assessment includes evaluating the level of consciousness and motor function as they are key components in assessing neurological function. Choices B, C, and D are incorrect as headache, nausea, reflexes, pupil size, tremors, and confusion may be part of a neurological assessment but are not the key components that are fundamental for a comprehensive assessment.
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