LPN LPN
ATI PN Comprehensive Predictor 2024
1. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?
- A. Decerebrate posturing.
- B. Hypervigilance.
- C. Absence of deep tendon reflexes.
- D. Glasgow Coma Scale score of 15.
Correct answer: A
Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.
2. What is the best nursing intervention for a patient with hyperkalemia?
- A. Administer potassium-wasting diuretics
- B. Encourage a low-potassium diet
- C. Administer potassium supplements
- D. Administer IV fluids
Correct answer: A
Rationale: The correct answer is to administer potassium-wasting diuretics. Hyperkalemia, which is high potassium levels, is managed by promoting the excretion of potassium from the body. Potassium-wasting diuretics help the kidneys eliminate excess potassium. Encouraging a low-potassium diet (choice B) is important for long-term management but not the immediate intervention for hyperkalemia. Administering potassium supplements (choice C) would worsen the condition by further increasing potassium levels. Administering IV fluids (choice D) may help with hydration but does not directly address the high potassium levels characteristic of hyperkalemia.
3. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, 'She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore.' Which suggestions should the nurse make to the daughter?
- A. Ask the client's physician for a strong sleep medicine
- B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime
- C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day
- D. Promote relaxation before bedtime with a warm bath or relaxing music
Correct answer: B
Rationale: The correct answer is to establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. By creating a structured daily schedule, the client's natural sleep-wake cycle can be regulated, helping to address the issue of daytime sleeping and nighttime wakefulness. Option A, asking for a strong sleep medicine, may not address the underlying cause and can have potential side effects in the elderly. Option C, engaging in exercises when drowsy, may not be suitable for someone with dementia and could disrupt sleep patterns further. Option D, promoting relaxation before bedtime, is helpful but may not be sufficient to address the client's significant sleep issue.
4. A client with hypothyroidism may present with which of the following findings?
- A. Weight gain
- B. Hair loss
- C. Dry skin
- D. Diarrhea
Correct answer: C
Rationale: Dry skin is a common manifestation of hypothyroidism due to decreased thyroid hormone levels, leading to reduced sweating and oil production. Weight gain may occur due to a slowed metabolism, not diarrhea, as hypothyroidism is more commonly associated with constipation. Hair loss is typically associated with hyperthyroidism, not hypothyroidism.
5. What is the appropriate intervention for a patient experiencing hypovolemic shock?
- A. Administer IV fluids
- B. Monitor blood pressure
- C. Place the patient in Trendelenburg position
- D. Administer oxygen
Correct answer: A
Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.
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