ATI RN
ATI Nursing Care of Children
1. The nurse is aware that skin turgor best estimates what?
- A. Perfusion
- B. Adequate hydration
- C. Amount of body fat
- D. Amount of anemia
Correct answer: B
Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.
2. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
- A. Breathing so rapidly interferes with oxygenation.
- B. Maybe the client has respiratory distress syndrome.
- C. The blood clot interferes with perfusion in the lungs.
- D. The client needs immediate intubation & mechanical ventilation.
Correct answer: C
Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.
3. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?
- A. Provide reality orientation throughout the day.
- B. Limit the client's choices to prevent decision fatigue.
- C. Encourage the client to participate in group therapy.
- D. Engage the client in sensory stimulation activities.
Correct answer: A
Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.
4. A client with hypertension is being taught about lifestyle modifications. Which statement by the client indicates a need for further teaching?
- A. I will reduce my sodium intake to help control my blood pressure.
- B. I need to start walking at least 30 minutes most days of the week.
- C. I can continue drinking alcohol as long as it is not in excess.
- D. I will check my blood pressure regularly at home.
Correct answer: C
Rationale: In hypertension management, it is crucial for clients to limit or avoid alcohol consumption, not just refrain from excess. Alcohol can raise blood pressure and interfere with the effectiveness of antihypertensive medications, making it a key lifestyle modification for individuals with hypertension.
5. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?
- A. 1 year
- B. 4 years
- C. 8 years
- D. 13 years
Correct answer: C
Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.
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