ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?
- A. Stage III pressure injury
- B. A stage II pressure injury
- C. A non-staging pressure injury
- D. Stage IV pressure injury
Correct answer: Stage IV pressure injury
Rationale:
2. Fat-soluble vitamins are different from water-soluble vitamins because the body is able to store only small amounts of fat-soluble vitamins.
- A. Both the statement and the reason are correct and related.
- B. Both the statement and the reason are correct but are not related.
- C. The statement is correct, but the reason is not correct.
- D. The statement is not correct, but the reason is correct.
Correct answer: C
Rationale: The statement is correct, but the reason is not correct. A major difference between fat-soluble and water-soluble vitamins is that the body is able to store larger amounts of fat-soluble vitamins. Vitamins A and D are stored for long periods; therefore, minor shortages might not be identified until drastic depletion has occurred. Observable signs and symptoms of a dietary deficiency are often not identified until they are in an advanced state. Water-soluble vitamins, on the other hand, are not stored in the body and are excreted in the urine if taken in excess, making it harder to reach toxic levels.
3. An important part of nutrition therapy for patients with cystic fibrosis is:
- A. A low-fat diet to prevent steatorrhea
- B. A low-sodium diet to normalize fluid status
- C. A high-fiber diet to normalize bowel function
- D. Pancreatic enzyme replacement therapy to help digestion
Correct answer: D
Rationale: The correct answer is D: Pancreatic enzyme replacement therapy to help digestion. In cystic fibrosis, pancreatic insufficiency leads to the malabsorption of nutrients, making it essential for patients to take pancreatic enzymes to aid in digestion. Options A, B, and C are incorrect because a low-fat diet may not provide adequate nutrition for cystic fibrosis patients, a low-sodium diet is not the primary focus of nutrition therapy in cystic fibrosis, and a high-fiber diet may exacerbate gastrointestinal symptoms due to malabsorption.
4. Which of the following actions are individuals with loss of smell NOT inclined to do?
- A. Use more spices in their food
- B. Eat less food
- C. Eat and drink more sweets
- D. Lose weight
Correct answer: D
Rationale: Individuals with a loss of smell are typically inclined to eat less because the enjoyment of food is diminished due to the lack of taste. However, they may compensate for this loss by consuming more sweets or using more spices. Therefore, they are less inclined to lose weight because of the increased consumption of sweets and spices, not because they eat less. Choice 'A' is incorrect because individuals with loss of smell often use more spices to enhance the taste of their food. Choice 'B' is incorrect as they may indeed eat less due to the diminished enjoyment of food. Choice 'C' is also incorrect as they tend to eat and drink more sweets to compensate for their loss of taste.
5. Which of the following best describes intrinsic values?
- A. Intrinsic values are often abstract ideas.
- B. Intrinsic values are basic needs for sustaining life.
- C. Intrinsic values are qualities patients consider to be important in their private lives.
- D. Intrinsic values are qualities patients consider important for nurses to have.
Correct answer: B
Rationale: The correct answer is B. Intrinsic values refer to basic needs for sustaining life, such as food, water, shelter, and safety. Choices A, C, and D are incorrect because intrinsic values are not abstract ideas, qualities important in private lives, or qualities important for nurses to have.
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