ATI Med-Surg Proctored Exam Latest Updated Solution 100% CORRECT. ATI MED SURG PROCTORED EXAM (Detail Solutions)

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? “Is there anything that you are stressed about right now that I should a. know?” b. “What reasons do you think are contributing to your fatigue?” c. “What are your normal work hours?” d. “Are you sleeping 8 hours a night?” ANS: B The question asking the patient what factors might be contributing to the fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed- ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of- fact response and does not prompt the patient to elaborate on the daytime fatigue or ask about the contributing reasons. 2. A nurse is conducting a nursing health history. Which component will the nurse address? a. Nurse’s concerns b. Patient expectations c. Current treatment orders d. Nurse’s goals for the patient ANS: B Some components of a nursing health history include chief concern, p a t i e n t 1 expectations, spiritual health, and review of systems. Current treatment orders are located under the Orders section in the patient’s chart and are not a part of the nursing health history. Patient concerns, not nurse’s concerns, are included in the database. Goals that are mutually established, not nurse’s goals, are part of the nursing care plan. 3. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a. Tell the patient to just focus on the leg and cast right now. b. Document the sleep patterns and information in the patient’s chart. c. Explain that a more thorough assessment will be needed next shift. Ask the patient about usual sleep patterns and the onset of having d. difficulty resting. ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient’s report of a problem or postpone it till the next shift. 4. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a. Gordon’s Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment ANS: D 2 The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problemoriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question. 5. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. “Data interpretation occurs before data validation.” b. “Validation involves looking for patterns in professional standards.” c. “Validation involves comparing data with other sources for accuracy.” “Data interpretation involves discovering patterns in professional d. standards.” ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards. 6. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new a. drainage. The nurse administers pain medicine due at 1700 at 1600 because the b. patient reports increased pain and the family wants something done. The nurse immediately asks the health care provider for an order of c. potassium when a patient reports leg cramps.3 The nurse elevates a leg cast when the patient reports decreased d. mobility. ANS: A