Nutrition ATI Test

ATI RN

1. Knowing that for a comatose patient hearing is the last sense to be lost, as Judyâ€™s nurse, what should you do?

A. Tell her family that probably she canâ€™t hear them
B. Talk loudly so that Wendy can hear you
C. Tell her family who are in the room not to talk
D. Speak softly then hold her hands gently

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

A. Fluid volume overload
B. Sepsis
C. Hyperglycemia
D. Hypoglycemia

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

3. What is the first step in decontamination?

A. Immediately applying a chemical decontamination foam to the area of contamination
B. Thoroughly washing and rinsing the patient with soap and water
C. Immediately applying personal protective equipment
D. Removing the patient's clothing and jewelry, then rinsing the patient with water

Correct answer: D

Rationale: The correct first step in decontamination is to remove the patient's clothing and jewelry to prevent further exposure and then rinse the patient with water. This helps to eliminate any contaminants on the patient's body. Choice A is incorrect because applying a chemical decontamination foam should come after removing clothing. Choice B is incorrect as washing and rinsing the patient should follow the removal of clothing. Choice C is incorrect as personal protective equipment should be worn by the individual performing the decontamination, not applied to the patient.

4. An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?

A. Marijuana
B. Amphetamines
C. Barbiturates
D. Anxiolytics

Correct answer: A

Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.

5. All of the following are seen in a child with measles. Which one is not?

A. Reddened eyes
B. Coryza
C. Pustule
D. Cough

Correct answer: C

Rationale: Measles typically presents with symptoms like reddened eyes, coryza (inflammation of the mucous membrane in the nose), and cough. However, pustules are not a common symptom of measles. Pustules are more characteristic of conditions like chickenpox rather than measles. Understanding these distinctions is crucial for accurate diagnosis and appropriate treatment.