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ATI PN Comprehensive Predictor 2020 Answers
1. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?
- A. Use a bed exit alarm system
- B. Raise all four side rails while the client is in bed
- C. Apply one soft wrist restraint
- D. Dim the lights in the client's room
Correct answer: A
Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.
2. A client who is newly diagnosed with iron deficiency anemia needs to include foods rich in iron in their diet. Which of the following foods should the nurse recommend as having the highest amount of iron?
- A. Boiled spinach
- B. Raw carrots
- C. Boiled chicken
- D. Yogurt
Correct answer: A
Rationale: Boiled spinach is an excellent source of iron, making it a top choice for individuals with iron deficiency anemia. Spinach contains non-heme iron, which may not be absorbed as efficiently as heme iron from animal sources but is still beneficial. Raw carrots, boiled chicken, and yogurt are not as rich in iron compared to spinach. Carrots are more known for their beta-carotene content, chicken is a good source of protein but not high in iron, and yogurt does not contain significant amounts of iron.
3. A nurse is caring for a client with dementia who frequently attempts to get out of bed unsupervised. What is the best intervention?
- A. Use restraints to prevent the client from getting out of bed
- B. Encourage family members to stay with the client at all times
- C. Use a bed exit alarm system
- D. Keep the client's room dark and quiet to reduce stimulation
Correct answer: C
Rationale: The best intervention for a client with dementia who frequently attempts to get out of bed unsupervised is to use a bed exit alarm system (Choice C). A bed exit alarm can alert staff when the client tries to leave the bed, helping to prevent falls. Using restraints (Choice A) is not recommended as it can lead to physical and psychological harm. While having family members present (Choice B) can be beneficial, it may not be feasible at all times. Keeping the client's room dark and quiet (Choice D) may not address the immediate safety concern of the client attempting to get out of bed.
4. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?
- A. Inspection, Palpation, Percussion, Auscultation
- B. Palpation, Inspection, Observation, Auscultation
- C. Percussion, Inspection, Auscultation, Palpation
- D. Inspection, Percussion, Auscultation, Palpation
Correct answer: A
Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.
5. A healthcare professional is collecting data from a client who has iron deficiency anemia. Which of the following findings should the healthcare professional expect?
- A. Increased energy
- B. Easy bruising
- C. Pale conjunctiva
- D. Weight gain
Correct answer: C
Rationale: Pale conjunctiva is a common sign of iron deficiency anemia due to reduced hemoglobin levels. This results in decreased oxygen-carrying capacity, leading to tissue hypoxia and pallor. 'Increased energy' (choice A) is not typically associated with iron deficiency anemia, as fatigue and weakness are common symptoms. 'Easy bruising' (choice B) is more characteristic of platelet disorders or vitamin deficiencies rather than iron deficiency anemia. 'Weight gain' (choice D) is not a typical finding in iron deficiency anemia; in fact, weight loss is more common due to decreased appetite and overall weakness.
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