ATI LPN
ATI PN Adult Medical Surgical 2019
1. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which side effect should the nurse monitor for?
- A. Hypertension
- B. Weight loss
- C. Hyperactivity
- D. Hyperglycemia
Correct answer: D
Rationale: The correct answer is D: Hyperglycemia. Risperidone (Risperdal) can lead to metabolic side effects, such as hyperglycemia, which requires monitoring. Choice A, Hypertension, is incorrect because risperidone is not typically associated with hypertension. Choice B, Weight loss, is less common with risperidone use as it can lead to weight gain. Choice C, Hyperactivity, is not a common side effect of risperidone; instead, it is more known for sedative effects.
2. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?
- A. The client uses a walker to move from the bed to the chair.
- B. The client has a strong cough.
- C. The client can bear weight on both legs.
- D. The client has a normal respiratory rate.
Correct answer: C
Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.
3. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?
- A. Apologize to the others for your behavior.
- B. I am disappointed that you continue to act out when you are angry.
- C. Come outside with me for a walk.
- D. If you don't calm down, you will have to go into seclusion.
Correct answer: C
Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.
4. A new mother asks the nurse when she should begin to breastfeed her newborn. The nurse's best response is:
- A. Within the first half-hour after birth
- B. After the newborn's first bath
- C. When the newborn begins to cry
- D. After administering vitamin K
Correct answer: A
Rationale: Initiating breastfeeding within the first half-hour after birth is crucial for successful breastfeeding and bonding, as recommended by the World Health Organization. This early initiation helps establish breastfeeding and supports the newborn's health by providing colostrum, the nutrient-rich first milk. Choice B, 'After the newborn's first bath,' is incorrect because initiating breastfeeding should not be delayed after birth. Choice C, 'When the newborn begins to cry,' is incorrect as it does not promote timely initiation of breastfeeding. Choice D, 'After administering vitamin K,' is incorrect because breastfeeding initiation should not be delayed for this procedure.
5. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?
- A. Inspection, percussion, palpation, auscultation
- B. Percussion, auscultation, inspection, palpation
- C. Auscultation, palpation, inspection, percussion
- D. Inspection, auscultation, percussion, palpation
Correct answer: D
Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.
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