ATI RN
Multi Dimensional Care | Final Exam
1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause for concern?
- A. The nurse assesses capillary refill of 2 seconds
- B. The nurse cannot insert one finger between the cast and the skin
- C. The nurse finds 2+ pulses distal from the cast
- D. The nurse does not observe any drainage
Correct answer: B
Rationale: Inability to insert a finger between the cast and skin indicates the cast is too tight, risking circulation problems.
2. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. FHR baseline 170/min.
- C. Early decelerations in the FHR.
- D. Temperature 37.4°C (99.3°F).
Correct answer: B
Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.
3. Picking up a pencil demonstrates the ability to use which of the following?
- A. Pincer grasp
- B. Prehension
- C. Parachute reflex
- D. Grasp reflex
Correct answer: A
Rationale: Picking up a pencil requires the use of the pincer grasp, which involves the coordination of the thumb and forefinger to hold small objects. The pincer grasp is a fine motor skill essential for tasks that necessitate precision and dexterity. Choices B, C, and D are incorrect. Prehension refers to the act of grasping or holding an object, parachute reflex is a protective response to sudden movement or loss of support, and grasp reflex is an automatic closing of the hand when an object is placed in the palm, none of which specifically relate to the action of picking up a pencil.
4. A nurse is providing oral hygiene for an unconscious client. What is the priority nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct answer: Position the client on one side with the head turned towards you
Rationale:
5. The parents of a school-age child ask the nurse if she thinks that their child has attention deficit hyperactivity disorder (ADHD). Which statement regarding the child’s behavior at school is most indicative of ADHD?
- A. He finishes his work on time in order to go to recess.
- B. He occasionally gets into trouble for talking.
- C. He enjoys math but does not like reading.
- D. He cannot sit still in his seat and constantly moves his legs.
Correct answer: D
Rationale: The most indicative behavior of ADHD is the inability to sit still and constant movement, known as hyperactivity. This behavior is a hallmark symptom of ADHD, making option D the correct choice. Options A, B, and C do not specifically reflect the characteristic hyperactivity associated with ADHD, making them less indicative of the disorder. While option B suggests impulsivity, it is not as specific to ADHD as the hyperactivity described in option D.
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