ATI LPN
PN Nutrition Assessment ATI
1. Individuals with optimal nutritional status differ from those with marginal nutritional status in their:
- A. nutrient reserves.
- B. clinical signs.
- C. body weight.
- D. risk of mental illness.
Correct answer: A
Rationale: Individuals with optimal nutritional status differ from those with marginal nutritional status in their nutrient reserves. Optimal nutritional status implies having adequate nutrient reserves, which is lacking in marginal status. Clinical signs (choice B) may or may not be present in both groups and are not the differentiating factor between optimal and marginal statuses. Body weight (choice C) can vary for reasons other than nutritional status. The risk of mental illness (choice D) is not directly related to the comparison between optimal and marginal nutritional status.
2. In schizophrenia, a patient is experiencing negative symptoms. Which of the following is a negative symptom?
- A. Hallucinations
- B. Delusions
- C. Apathy
- D. Disorganized speech
Correct answer: C
Rationale: In schizophrenia, negative symptoms refer to deficits in normal emotional responses or other thought processes. Apathy is a negative symptom characterized by a lack of interest, enthusiasm, or concern. Hallucinations (seeing or hearing things that aren't there), delusions (false beliefs), and disorganized speech are positive symptoms, which involve the presence of abnormal behaviors or thoughts.
3. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct answer: A
Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.
4. A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hours. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times?
- A. 2100
- B. 900
- C. 1300
- D. 1800
Correct answer: D
Rationale: The trough level of vancomycin should be drawn just before the next dose is administered, typically about 30 minutes before the scheduled dose. Since the morning dose is at 0700, the trough level should be drawn at 1800. This timing ensures an accurate measurement of the lowest concentration of the drug in the client's system before the next dose is given. Choice A (2100) is too close to the next dose, choice B (900) is too early, and choice C (1300) is also too far from the next dose.
5. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?
- A. Measure hourly urinary output for the postoperative patient.
- B. Administer medications to stable patients.
- C. Reinforce patient education.
- D. Initiate a care plan for a new patient.
Correct answer: A
Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.
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