ATI RN
ATI Comprehensive Exit Exam
1. A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?
- A. Increased urine output.
- B. Hyperactive reflexes.
- C. Hypoactive bowel sounds.
- D. Facial weakness.
Correct answer: D
Rationale: Facial weakness is a common finding in clients with Guillain-Barré syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barré syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barré syndrome, making it an incorrect choice.
2. 1. Which patient action indicates good understanding of the nurse�s teaching about administration of aspart (NovoLog) insulin?
- A. The patient avoids injecting the insulin into the upper abdominal area
- B. The patient cleans the skin with soap and water before insulin administration.
- C. The patient stores the insulin in the freezer after administering the prescribed dose.
- D. The patient pushes the plunger down while removing the syringe from the injection site
Correct answer: B
Rationale:
3. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
- A. I can give you information about respite care if you are interested.
- B. You should consider taking a sleeping pill before bed each night.
- C. It must be difficult taking care of someone who is terminally ill.
- D. You are doing a great job taking care of your mother.
Correct answer: A
Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.
4. A mother delivers an infant at 30 weeks gestation. The mother asks the nurse for information on nutrition and if formula would be better since the baby is premature. What is the foundation for the response to the mother by the nurse?
- A. Human milk is preferred over other types of nutrition.
- B. Human milk lacks essential nutrients when the infant is preterm.
- C. Commercial infant formulas are preferred over other types of nutrition.
- D. Commercial infant formulas have not been designed to meet the nutritional needs of preterm infants.
Correct answer: A
Rationale: The correct answer is A. Human milk is the preferred food for infants, including preterm infants. It contains essential ingredients necessary for the infant's growth and development. The mother should pump her breasts to provide milk for the infant if the child is receiving enteral feedings. Once the infant can coordinate breathing, sucking, and swallowing, breastfeeding directly is encouraged. Studies have shown that preterm infants fed fortified human milk have better outcomes compared to those fed commercial infant formulas. Commercial infant formulas may not fully meet the unique nutritional needs of preterm infants, leading to potential longer hospital stays. Therefore, human milk is the best choice for feeding premature infants.
5. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?
- A. Encourage the client to spend time in the day room.
- B. Withdraw the client's TV privileges if they do not attend group therapy.
- C. Encourage the client to take frequent rest periods.
- D. Place the client in seclusion when they exhibit signs of anxiety.
Correct answer: C
Rationale: Encouraging the client to take frequent rest periods is the appropriate intervention when caring for a client with bipolar disorder experiencing mania. During manic episodes, individuals often exhibit hyperactivity and may become exhausted. Rest periods can help reduce these symptoms. Choices A, B, and D are incorrect. Spending time in the day room may not address the client's need for rest, withdrawing TV privileges is not directly related to managing mania symptoms, and placing the client in seclusion when anxious can escalate the situation rather than promoting a calming environment.
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