ATI LPN
PN Nutrition Assessment ATI
1. Which observation provides evidence that a person has good nutritional status?
- A. Small muscle mass.
- B. Normal weight-to-height ratio.
- C. Smooth tongue.
- D. Fragile skin.
Correct answer: B
Rationale: A normal weight-to-height ratio is a reliable indicator of good nutritional status as it suggests that the person is well-nourished and not underweight or overweight. Small muscle mass (choice A) can indicate malnutrition, a smooth tongue (choice C) can be a sign of vitamin deficiencies, and fragile skin (choice D) can be a sign of poor nutrition or other health issues, but they are not as direct indicators of good nutritional status as a normal weight-to-height ratio.
2. A client with chronic kidney disease (CKD) is experiencing hyperkalemia. Which intervention should the nurse implement to address this condition?
- A. Administer calcium gluconate.
- B. Encourage a diet high in potassium.
- C. Provide potassium supplements.
- D. Restrict sodium intake.
Correct answer: A
Rationale: Administering calcium gluconate is the appropriate intervention for a client with hyperkalemia. Calcium gluconate helps stabilize the heart by counteracting the effects of high potassium levels and reducing the risk of cardiac complications in individuals with hyperkalemia. Choices B, C, and D are incorrect. Encouraging a diet high in potassium or providing potassium supplements would exacerbate hyperkalemia. Restricting sodium intake is not directly related to addressing hyperkalemia.
3. Which term specifically refers to positive actions taken to help others?
- A. Beneficence
- B. Justice
- C. Autonomy
- D. Non-maleficence
Correct answer: A
Rationale: The correct answer is A, 'Beneficence.' Beneficence is the ethical principle that involves taking positive actions to help others. Choice B, 'Justice,' pertains to fairness and equity in treatment, not specifically positive actions. Choice C, 'Autonomy,' relates to respecting individuals' rights to make their own decisions, not necessarily taking actions to help others. Choice D, 'Non-maleficence,' focuses on the obligation to avoid causing harm rather than actively helping others.
4. What teaching points are important for the nurse to discuss with a client with hearing loss who has been fitted for a hearing aid?
- A. Use the highest setting to promote full auditory comprehension
- B. Use mild soap and water to clean the ear mold
- C. Turn the hearing aid off to conserve battery life during hours of sleep only
- D. Immerse the hearing aid in saline solution to keep it hygienic
Correct answer: B
Rationale: The correct teaching point for a client with hearing loss who has been fitted for a hearing aid is to use mild soap and water to clean the ear mold. It is important to keep the ear mold clean to prevent infections and maintain proper functioning. Choice A is incorrect because using the highest setting can lead to discomfort and may not be necessary for all situations. Choice C is incorrect as the hearing aid should generally be turned off when not in use, not just during sleep, to conserve battery life. Choice D is incorrect as immersing the hearing aid in saline solution can damage the device; it should be kept dry to prevent malfunction.
5. What are the signs of an acute myocardial infarction?
- A. Chest pain radiating to the arm and shortness of breath
- B. Nausea, vomiting, and high fever
- C. Headache, confusion, and low blood pressure
- D. Increased heart rate and bradycardia
Correct answer: A
Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.
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