ATI LPN
PN ATI Comprehensive Predictor
1. A nurse is caring for a client who has hypokalemia. Which of the following clinical findings should the nurse expect?
- A. Hyperactive reflexes.
- B. Strong, bounding pulse.
- C. Decreased bowel sounds.
- D. Increased deep tendon reflexes.
Correct answer: C
Rationale: The correct answer is C: Decreased bowel sounds. In hypokalemia, decreased bowel sounds are common due to slowed peristalsis. Hyperactive reflexes (choice A) and increased deep tendon reflexes (choice D) are more indicative of hyperkalemia. A strong, bounding pulse (choice B) is not typically associated with hypokalemia.
2. Which therapeutic intervention is most appropriate for a patient diagnosed with dissociative amnesia?
- A. Cognitive-behavioral therapy
- B. Hypnotherapy
- C. Electroconvulsive therapy
- D. Pharmacotherapy
Correct answer: B
Rationale: Hypnotherapy is the most appropriate therapeutic intervention for a patient diagnosed with dissociative amnesia. This approach aims to help the patient recover lost memories in a controlled environment, allowing them to process and integrate their memories effectively. Hypnotherapy can assist in uncovering and addressing the underlying issues contributing to dissociative amnesia. Cognitive-behavioral therapy focuses on changing negative patterns of thinking or behavior and may not directly address memory recovery. Electroconvulsive therapy is typically used for severe depression or certain mental disorders, not dissociative amnesia. Pharmacotherapy involves medication and is not the primary intervention for dissociative amnesia.
3. What is the most appropriate intervention for a client with phlebitis at the IV site?
- A. Apply a warm compress to the site
- B. Discontinue the IV and notify the provider
- C. Increase the IV flow rate to prevent dehydration
- D. Monitor the site for signs of infection
Correct answer: B
Rationale: The most appropriate intervention for a client with phlebitis at the IV site is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and continuing the IV can lead to complications such as infection or thrombosis. Applying a warm compress may provide symptomatic relief but does not address the root cause. Increasing the IV flow rate is not indicated and may worsen the inflammation. Monitoring for signs of infection is important, but the priority is to remove the source of inflammation by discontinuing the IV.
4. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, 'She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore.' Which suggestions should the nurse make to the daughter?
- A. Ask the client's physician for a strong sleep medicine
- B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime
- C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day
- D. Promote relaxation before bedtime with a warm bath or relaxing music
Correct answer: B
Rationale: The correct answer is to establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. By creating a structured daily schedule, the client's natural sleep-wake cycle can be regulated, helping to address the issue of daytime sleeping and nighttime wakefulness. Option A, asking for a strong sleep medicine, may not address the underlying cause and can have potential side effects in the elderly. Option C, engaging in exercises when drowsy, may not be suitable for someone with dementia and could disrupt sleep patterns further. Option D, promoting relaxation before bedtime, is helpful but may not be sufficient to address the client's significant sleep issue.
5. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?
- A. Assess the client's allergies.
- B. Monitor the client's vital signs.
- C. Inform the client of potential side effects.
- D. Obtain the client's informed consent.
Correct answer: A
Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.
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