ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
- A. Client will increase mobility by the time of discharge from hospital
- B. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay
- C. Client will increase activity tolerance by discharge from the hospital
- D. Client will remain free from falls throughout their hospital stay
Correct answer: Client will remain free from falls throughout their hospital stay
Rationale:
2. Substance abuse is different from substance dependence in that, substance dependence:
- A. includes characteristics of adverse consequences and repeated use
- B. requires long term treatment in a hospital based program
- C. produces less severe symptoms than that of abuse
- D. includes characteristics of tolerance and withdrawal
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
3. A client has a new prescription for Warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider immediately?
- A. INR of 4.0
- B. Potassium level of 4.5 mEq/L
- C. Sodium level of 140 mEq/L
- D. Creatinine level of 1.0 mg/dL
Correct answer: A
Rationale: An INR of 4.0 is above the therapeutic range for a client on Warfarin, indicating an increased risk of bleeding. This finding requires immediate reporting to the provider for appropriate intervention to prevent complications associated with excessive anticoagulation. Potassium, sodium, and creatinine levels are within normal ranges and are not directly related to the risk of bleeding in a client on Warfarin therapy.
4. What problem is most often associated with myelomeningocele?
- A. Biliary atresia
- B. Hydrocephalus
- C. Craniostenosis
- D. Tracheoesophageal fistula
Correct answer: B
Rationale: Hydrocephalus is the most commonly associated problem with myelomeningocele, present in 80% to 90% of affected children. Biliary atresia and tracheoesophageal fistula are not typically associated with myelomeningocele. Craniostenosis refers to the premature closing of cranial sutures and is not a common issue seen with myelomeningocele.
5. Which of the following is a common criticism against Piaget's theory of cognitive development?
- A. The sequence of stages is not fixed.
- B. Research has not supported the existence of the preoperational stage.
- C. Piaget put a heavy emphasis on the environment, ignoring the importance of mental processes.
- D. Children develop abilities earlier than Piaget theorized.
Correct answer: D
Rationale: The correct answer is D because one common criticism of Piaget's theory is that children often acquire cognitive abilities earlier than Piaget proposed. This criticism suggests that Piaget's stages might not be as fixed or rigid as he believed. Choices A, B, and C are incorrect: A is a characteristic of Piaget's theory; B is not a common criticism, as research generally supports the existence of Piaget's stages; and C is inaccurate, as Piaget actually emphasized the importance of mental processes in cognitive development.
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