ATI LPN
PN Nutrition Assessment ATI
1. Signs of malnutrition can appear when:
- A. nutrient reserves are depleted.
- B. nutrient intake exceeds daily needs.
- C. energy intake is restricted.
- D. caloric expenditure increases.
Correct answer: A
Rationale: The correct answer is A: 'nutrient reserves are depleted.' Signs of malnutrition manifest when the body's reserves of essential nutrients are exhausted and can no longer sustain health. Choice B is incorrect because excessive nutrient intake exceeding daily needs does not lead to malnutrition but may cause other health issues. Choice C is incorrect as restricting energy intake may lead to weight loss but not necessarily malnutrition. Choice D is also incorrect as increasing caloric expenditure does not directly cause malnutrition.
2. A nurse is providing education to a client about a new prescription for digoxin. Which of the following should be included?
- A. Monitor for increased heart rate
- B. Take the medication at the same time every day
- C. It should be stopped abruptly
- D. Avoid potassium-rich foods
Correct answer: B
Rationale: The correct answer is B: 'Take the medication at the same time every day.' Clients should take digoxin at the same time each day to maintain consistent therapeutic levels, enhancing the drug's effectiveness and minimizing fluctuations in blood concentration. Choice A is incorrect because digoxin, as a medication, may actually help in controlling the heart rate. Choice C is incorrect as digoxin should never be stopped abruptly due to the risk of rebound effects and worsening of the condition. Choice D is unrelated to digoxin therapy, as it is more relevant to medications like potassium-sparing diuretics.
3. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?
- A. Use the cane on the stronger side of the body
- B. Maintain two points of support on the floor at all times
- C. Advance the cane and the strong leg together
- D. Advance the cane 30 to 45 cm with each step
Correct answer: B
Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.
4. A client is receiving morphine for pain. Which of the following assessments is the priority?
- A. Urine output
- B. Pupil reaction
- C. Respiratory rate
- D. Bowel sounds
Correct answer: C
Rationale: The correct answer is C: Respiratory rate. Monitoring the respiratory rate is the priority assessment for a client receiving morphine due to the risk of respiratory depression. Morphine is a potent opioid that can cause respiratory depression, which is a serious adverse effect that can be life-threatening. Assessing the client's respiratory rate is crucial to detect any signs of respiratory depression early and intervene promptly. Assessing urine output is important but not as critical as monitoring for respiratory depression with morphine. Pupil reaction and bowel sounds are also important assessments but do not take precedence over monitoring the respiratory rate when a client is on morphine.
5. A nurse is caring for a client with a new prescription for clindamycin. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum potassium
- C. Signs of superinfection
- D. Blood glucose
Correct answer: C
Rationale: The correct answer is C: Signs of superinfection. Clindamycin can lead to antibiotic-associated colitis and other superinfections, making it crucial for the nurse to monitor the client for signs of superinfection. Monitoring liver function (choice A) is not typically associated with clindamycin use. Serum potassium levels (choice B) and blood glucose (choice D) are also not directly affected by clindamycin, so they are not the priority for monitoring in this case.
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