ATI RN
ATI RN Custom Exams Set 1
1. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)
- A. Obtain the pulses in all four extremities
- B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
- C. Determine the client’s orientation to person, place, and time
- D. B, C
Correct answer: D
Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.
2. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?
- A. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor
- B. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes
- C. Reach over to the left side rail with your right hand, pull your body onto its side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk
- D. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress
Correct answer: C
Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.
3. What causes hepatic encephalopathy?
- A. Buildup of ammonia in the body
- B. Buildup of urea in the body
- C. Fatty infiltration of the liver
- D. Jaundice
Correct answer: A
Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body. Ammonia, a byproduct of protein metabolism, normally gets converted to urea in the liver for excretion. However, in liver dysfunction, such as cirrhosis, the liver cannot effectively convert ammonia to urea, leading to its accumulation in the body and subsequently causing hepatic encephalopathy. Choices B, C, and D are incorrect as they do not directly relate to the pathophysiology of hepatic encephalopathy.
4. For a patient on lithium therapy, which dietary recommendation is essential?
- A. Increase caffeine intake
- B. Increase sodium intake
- C. Increase protein intake
- D. Increase fiber intake
Correct answer: B
Rationale: The correct answer is to increase sodium intake. For patients on lithium therapy, maintaining consistent sodium intake is crucial to avoid fluctuations in drug levels. Increasing caffeine intake (choice A) is not recommended as it can interfere with lithium levels. While protein intake (choice C) is important for overall health, it is not specifically essential for patients on lithium therapy. Similarly, increasing fiber intake (choice D) is beneficial but not a primary concern for patients on lithium therapy.
5. Which of the following grains is acceptable for someone with celiac disease?
- A. Rice
- B. Rye
- C. Wheat
- D. Barley
Correct answer: A
Rationale: The correct answer is A, Rice. Rice is a gluten-free grain and is safe for individuals with celiac disease. Rye, wheat, and barley contain gluten, which can trigger adverse reactions in individuals with celiac disease. Therefore, choices B, C, and D are incorrect for someone with this condition.
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