ATI RN
ATI Nutrition Proctored
1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?
- A. severity of illness
- B. presence of pressure sores
- C. localized edema
- D. generalized weakness
Correct answer: D
Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.
2. What reflex protects an infant from strong stimulation?
- A. Moro
- B. eye-blink
- C. sucking
- D. palmar grasp
Correct answer: B
Rationale: The correct answer is B: eye-blink. The eye-blink reflex is the one that protects an infant from strong stimulation by causing them to quickly shut their eyes in response to sudden bright light or a loud noise. This reflex helps to safeguard the infant's sensitive eyes from potential harm. The Moro reflex (choice A) is the startle reflex, the sucking reflex (choice C) helps with feeding, and the palmar grasp reflex (choice D) is when the infant's fingers close around an object placed in their hand; none of these reflexes specifically protect the infant from strong stimulation.
3. What is the first action to take for a patient experiencing a seizure?
- A. Administer anticonvulsant medication
- B. Protect the patient's head
- C. Insert an oral airway
- D. Restrain the patient
Correct answer: B
Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.
4. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 140/90 mm Hg
- B. Heart rate of 88/min
- C. LDL cholesterol 110 mg/dL
- D. Respiratory rate of 16/min
Correct answer: D
Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.
5. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?
- A. White blood cell count (WBC)
- B. C-reactive protein (CRP)
- C. Erythrocyte sedimentation rate (ESR)
- D. Hemoglobin and hematocrit levels
Correct answer: A
Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.