ATI RN
ATI RN Custom Exams Set 4
1. Which endocrine disorder would the nurse assess for in a client who has a closed head injury with increased intracranial pressure?
- A. Pheochromocytoma
- B. Diabetes insipidus
- C. Hashimoto’s disease
- D. Gynecomastia
Correct answer: B
Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (choice A) is a tumor of the adrenal gland and is not directly related to closed head injury or increased intracranial pressure. Hashimoto’s disease (choice C) is an autoimmune disorder affecting the thyroid gland, not commonly associated with head injuries. Gynecomastia (choice D) is the development of breast tissue in males and is not an endocrine disorder typically linked to closed head injuries.
2. Management experience prepares the practical nurse to be a Clinical NCO or a Senior Clinical NCO. These positions are normally held by which of the following?
- A. Army Nurse Corps officer
- B. First Sergeant
- C. E6, E7, or E8
- D. E3, E4, or E5
Correct answer: C
Rationale: The correct answer is C: E6, E7, or E8. Clinical NCO or Senior Clinical NCO positions are typically held by individuals at the E6, E7, or E8 pay grades in the military. These positions require a higher level of experience and leadership, which align with the ranks of E6, E7, or E8. Choices A, B, and D are incorrect because Army Nurse Corps officers, First Sergeants, E3, E4, or E5 are not the typical ranks that hold Clinical NCO positions.
3. The nurse is caring for a client diagnosed with rule-out nephritic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding
- B. Evaluate the calorie count of the 500-mg protein diet
- C. Assess the client’s sacrum for dependent edema
- D. Monitor for a high serum albumin level
Correct answer: C
Rationale: The correct intervention to include in the plan of care for a client with rule-out nephritic syndrome is to assess the client’s sacrum for dependent edema. Dependent edema is common in nephritic syndrome due to protein loss, and monitoring for this helps manage the condition. Choices A, B, and D are incorrect. Monitoring the urine for bright-red bleeding may be more relevant for a client with a different condition, such as glomerulonephritis. Evaluating the calorie count of a 500-mg protein diet is not directly related to managing nephritic syndrome. Monitoring for a high serum albumin level does not directly address the symptom of dependent edema associated with nephritic syndrome.
4. Protecting the rights and privacy of the patient and their family is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?
- A. Evaluation
- B. Planning
- C. Implementation
- D. Assessment
Correct answer: C
Rationale: In nursing care, implementation involves putting the nursing care plan into action. This step includes safeguarding the rights and privacy of the patient and their family by providing care in a respectful and confidential manner. Evaluation (A) is about assessing the effectiveness of the care provided. Planning (B) is the stage where specific interventions are designed. Assessment (D) is the initial step where data is collected to identify the patient's needs.
5. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)
- A. The nurse removes the foam boot three times per day to inspect the skin
- B. The staff turn the client to the unaffected side
- C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
- D. The nurse asks the client to dorsiflex the foot on the affected leg
Correct answer: C
Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.
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