LPN LPN
ATI PN Comprehensive Predictor 2020 Answers
1. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?
- A. I see that you are feeling overwhelmed. I will come back when you are ready
- B. This is normal, and I will check on you later
- C. You are feeling frustrated. Let's talk about your concerns.
- D. You will feel better soon. Let me get you some water.
Correct answer: A
Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.
2. A nurse is planning care for a client who is at 28 weeks of gestation and has preeclampsia. Which of the following interventions should the nurse include in the plan?
- A. Restrict the client's fluid intake.
- B. Monitor the client's deep-tendon reflexes.
- C. Place the client in the lithotomy position.
- D. Encourage the client to ambulate frequently.
Correct answer: B
Rationale: The correct answer is to monitor the client's deep-tendon reflexes. Monitoring deep-tendon reflexes is crucial in clients with preeclampsia as hyperreflexia can indicate severe complications. Restricting the client's fluid intake is not recommended as hydration is essential. Placing the client in the lithotomy position can worsen preeclampsia by reducing blood flow to the heart, so it should be avoided. Encouraging the client to ambulate frequently may not be suitable for a client with preeclampsia due to the risk of falls and increased stress on the body.
3. A nurse is caring for a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Tachycardia
- C. Hypotension
- D. Diaphoresis
Correct answer: A
Rationale: Corrected Rationale: Bradycardia is a common sign of hypoglycemia due to the body's response to low blood sugar. During hypoglycemia, the body releases epinephrine, leading to sympathetic nervous system activation. This can result in bradycardia as a compensatory mechanism to preserve glucose for vital organs such as the brain. Tachycardia, hypotension, and diaphoresis are more commonly associated with hypoglycemia when it progresses to severe stages and the body's compensatory mechanisms are overwhelmed.
4. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?
- A. Assess for bladder distention after 4 hours
- B. Pour warm water over the perineum
- C. Restrict the client's oral fluid intake
- D. Restrict movement for at least 12 hours
Correct answer: B
Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.
5. What is the priority intervention when managing a client with delirium?
- A. Administer antipsychotic medication to calm the client
- B. Identify any reversible causes of delirium
- C. Provide a low-stimulation environment
- D. Administer sedative medication to control agitation
Correct answer: B
Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.
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