ATI Comprehensive Exit Exam c c c
(Detail Solutions) c
1. A patient’s father died a week ago. Both the patient and the patient’s spous
c c c c c c c c c c c c c
e talk about the death. The patient’s spouse is experiencing headachesand fati
c c c c c c c c c c c c
gue. The patient is having trouble sleeping, has no appetite, and gets
c c c c c c c c c c c
choked up most of the time. How should the nurse interpret these findings asthe
c c c c c c c c c c c c c c
basis for a follow-up assessment?
c c c c c
a. The patient is dying and the spouse is angry.
c c c c c c c c
b. The patient is ill and the spouse is malingering.
c c c c c c c c
c. Both the patient and the spouse are likely in denial.
c c c c c c c c c
d. Both the patient and the spouse are likely grieving.
c c c c c c c c
ANS: D c
Both are likely grieving from the loss of the patient’s father. Symptoms of norm
c c c c c c c c c c c c c
al grief include headache, fatigue, insomnia, appetite disturbance, and choking s
c c c c c c c c c c
ensation. Different people manifest different symptoms. There is nodata to supp
c c c c c c c c c c c
ort the spouse is angry or malingering. There is no data to supportthe patient is d
c c c c c c c c c c c c c c c c
ying or ill. Denial is assessed when the person cannot accept the loss; both talked
c c c c c c c c c c c c c c
about the loss.
c c c
MULTIPLE RESPONSE c
1. A nurse is documenting end-of-life care. Which information will the
c c c c c c c c c
nurse include in the patient’s electronic medical record? (Select all thatapply.)
c c c c c c c c c c c
a. Reason for the death c c c
b. Time and date of death c c c c
c. How ethically the family grieved
c c c c
d. Location of body identification tags c c c c
1
e. Time of body transfer and destination
c c c c c
,ANS: B, D, E c c c
Documentation of end-of- c c
life care includes the following: time and date of death, location of body identific
c c c c c c c c c c c c c
ation tags, time of body transfer and destination and personal articles left on and s
c c c c c c c c c c c c c c
ecured to the body. Reason for the death is not appropriate; this is a medical judg
c c c c c c c c c c c c c c c
ment and not a nursing judgment. How ethically the family grieved is judgmental
c c c c c c c c c c c c
cand does not belongin the chart. We must remain open to the varying views and b
c c c c c c c c c c c c c c c c
eliefs of grievingthat are in contrast to our own in order to best support and care fo
c c c c c c c c c c c c c c c c c
r our patientsand their families.
c c c c c
Week 3 c
Safety and Fall Prevention among Older Adults, Preventing Complications ofIm
c c c c c c c c c c
mobility
1. A home health nurse is performing a home assessment for safety.
c c c c c c c c c c c
Which comment by the patient will cause the nurse to follow up?
c c c c c c c c c c c
“Every December is the time to change batteries on the carbonc c c c c c c c c c
a. monoxide detector.” c
b. “I will schedule an appointment with a chimney inspector next week.”
c c c c c c c c c c
c. “If I feel dizzy when using the heater, I need to have it inspected.”
c c c c c c c c c c c c c
d. “When it is cold outside in the winter, I will use a nonvented furnace.”
c c c c c c c c c c c c c
ANS: D c
Using a nonvented heater introduces carbon monoxide into the environmenta
c c c c c c c c c c
nd decreases the available oxygen for human consumption and the nurse shoul
c c c c c c c c c c c
d follow up to correct this behavior. Checking the chimney and heater,changin
c c c c c c c c c c c c
g the batteries on the detector, and following up on symptoms such as dizzines
c c c c c c c c c c c c c
s, nausea, and fatigue are all statements that are safe and appropriate and need
c c c c c c c c c c c c c c
no follow-up.
c
2. The nurse is caring for an older- c c c c c c
adult patient admitted with nausea,vomiting, and diarrhea due to food pois
c c c c c c c c c c c
oning. The nurse completes the c c c c
health history. Which priority concern will require collaboration withsoc
c c c c c c c c c
ial services to address the patient’s health care needs?
c c c c c c c c
a. The electricity was turned off 3 days ago. c c c c c c c
2
b. The water comes from the county water supply.c c c c c c c
, c. A son and family recently moved into the home.
c c c c c c c c
d. This home is not furnished with a microwave oven.
c c c c c c c c
ANS: A c
Electricity is needed for refrigeration of food, and lack of electricity could have
c c c c c c c c c c c c c
contributed to the nausea, vomiting, and diarrhea due to food poisoning.This dis
c c c c c c c c c c c c
cussion about the patient’s electrical needs can be referred to social services. Fo
c c c c c c c c c c c c
ods that are inadequately prepared or stored or subject to unsanitary conditions i
c c c c c c c c c c c c
ncrease the patient’s risk for infections and food poisoning, and an assessment s
c c c c c c c c c c c c
hould include storage practices. The water supply, the increased number of indi
c c c c c c c c c c c
viduals in the home, and not having a microwave may or may not be concerns b
c c c c c c c c c c c c c c c
ut do not pertain to the current health care needs of this patient.
c c c c c c c c c c c c
3. The patient has been diagnosed with a respiratory illness and reportssh
c c c c c c c c c c c
ortness of breath. The nurse adjusts the temperature to facilitate the
c c c c c c c c c c
comfort of the patient. At which temperature range will the nurse set thethermo
c c c c c c c c c c c c c
stat?
a. 60° to 64° F c c c
b. 65° to 75° F c c c
c. 15° to 17° C c c c
d. 25° to 28° C c c c
ANS: B c
A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F).Th
c c c c c c c c c c c c c c c
e other ranges are too low or too high and do not reflect the average person’scomfo
c c c c c c c c c c c c c c c c
rt zone.
c
4. A homeless adult patient presents to the emergency department. The nu
c c c c c c c c c c
rse obtains the following vital signs: temperature 94.8° F, blood pressure
c c c c c c c c c c
106/56, apical pulse 58, and respiratory rate 12. Which vital sign should thenur
c c c c c c c c c c c c c
se address immediately?
c c
a. Respiratory rate c
3
b. Temperature
(Detail Solutions) c
1. A patient’s father died a week ago. Both the patient and the patient’s spous
c c c c c c c c c c c c c
e talk about the death. The patient’s spouse is experiencing headachesand fati
c c c c c c c c c c c c
gue. The patient is having trouble sleeping, has no appetite, and gets
c c c c c c c c c c c
choked up most of the time. How should the nurse interpret these findings asthe
c c c c c c c c c c c c c c
basis for a follow-up assessment?
c c c c c
a. The patient is dying and the spouse is angry.
c c c c c c c c
b. The patient is ill and the spouse is malingering.
c c c c c c c c
c. Both the patient and the spouse are likely in denial.
c c c c c c c c c
d. Both the patient and the spouse are likely grieving.
c c c c c c c c
ANS: D c
Both are likely grieving from the loss of the patient’s father. Symptoms of norm
c c c c c c c c c c c c c
al grief include headache, fatigue, insomnia, appetite disturbance, and choking s
c c c c c c c c c c
ensation. Different people manifest different symptoms. There is nodata to supp
c c c c c c c c c c c
ort the spouse is angry or malingering. There is no data to supportthe patient is d
c c c c c c c c c c c c c c c c
ying or ill. Denial is assessed when the person cannot accept the loss; both talked
c c c c c c c c c c c c c c
about the loss.
c c c
MULTIPLE RESPONSE c
1. A nurse is documenting end-of-life care. Which information will the
c c c c c c c c c
nurse include in the patient’s electronic medical record? (Select all thatapply.)
c c c c c c c c c c c
a. Reason for the death c c c
b. Time and date of death c c c c
c. How ethically the family grieved
c c c c
d. Location of body identification tags c c c c
1
e. Time of body transfer and destination
c c c c c
,ANS: B, D, E c c c
Documentation of end-of- c c
life care includes the following: time and date of death, location of body identific
c c c c c c c c c c c c c
ation tags, time of body transfer and destination and personal articles left on and s
c c c c c c c c c c c c c c
ecured to the body. Reason for the death is not appropriate; this is a medical judg
c c c c c c c c c c c c c c c
ment and not a nursing judgment. How ethically the family grieved is judgmental
c c c c c c c c c c c c
cand does not belongin the chart. We must remain open to the varying views and b
c c c c c c c c c c c c c c c c
eliefs of grievingthat are in contrast to our own in order to best support and care fo
c c c c c c c c c c c c c c c c c
r our patientsand their families.
c c c c c
Week 3 c
Safety and Fall Prevention among Older Adults, Preventing Complications ofIm
c c c c c c c c c c
mobility
1. A home health nurse is performing a home assessment for safety.
c c c c c c c c c c c
Which comment by the patient will cause the nurse to follow up?
c c c c c c c c c c c
“Every December is the time to change batteries on the carbonc c c c c c c c c c
a. monoxide detector.” c
b. “I will schedule an appointment with a chimney inspector next week.”
c c c c c c c c c c
c. “If I feel dizzy when using the heater, I need to have it inspected.”
c c c c c c c c c c c c c
d. “When it is cold outside in the winter, I will use a nonvented furnace.”
c c c c c c c c c c c c c
ANS: D c
Using a nonvented heater introduces carbon monoxide into the environmenta
c c c c c c c c c c
nd decreases the available oxygen for human consumption and the nurse shoul
c c c c c c c c c c c
d follow up to correct this behavior. Checking the chimney and heater,changin
c c c c c c c c c c c c
g the batteries on the detector, and following up on symptoms such as dizzines
c c c c c c c c c c c c c
s, nausea, and fatigue are all statements that are safe and appropriate and need
c c c c c c c c c c c c c c
no follow-up.
c
2. The nurse is caring for an older- c c c c c c
adult patient admitted with nausea,vomiting, and diarrhea due to food pois
c c c c c c c c c c c
oning. The nurse completes the c c c c
health history. Which priority concern will require collaboration withsoc
c c c c c c c c c
ial services to address the patient’s health care needs?
c c c c c c c c
a. The electricity was turned off 3 days ago. c c c c c c c
2
b. The water comes from the county water supply.c c c c c c c
, c. A son and family recently moved into the home.
c c c c c c c c
d. This home is not furnished with a microwave oven.
c c c c c c c c
ANS: A c
Electricity is needed for refrigeration of food, and lack of electricity could have
c c c c c c c c c c c c c
contributed to the nausea, vomiting, and diarrhea due to food poisoning.This dis
c c c c c c c c c c c c
cussion about the patient’s electrical needs can be referred to social services. Fo
c c c c c c c c c c c c
ods that are inadequately prepared or stored or subject to unsanitary conditions i
c c c c c c c c c c c c
ncrease the patient’s risk for infections and food poisoning, and an assessment s
c c c c c c c c c c c c
hould include storage practices. The water supply, the increased number of indi
c c c c c c c c c c c
viduals in the home, and not having a microwave may or may not be concerns b
c c c c c c c c c c c c c c c
ut do not pertain to the current health care needs of this patient.
c c c c c c c c c c c c
3. The patient has been diagnosed with a respiratory illness and reportssh
c c c c c c c c c c c
ortness of breath. The nurse adjusts the temperature to facilitate the
c c c c c c c c c c
comfort of the patient. At which temperature range will the nurse set thethermo
c c c c c c c c c c c c c
stat?
a. 60° to 64° F c c c
b. 65° to 75° F c c c
c. 15° to 17° C c c c
d. 25° to 28° C c c c
ANS: B c
A person’s comfort zone is usually between 18.3° and 23.9° C (65° and 75° F).Th
c c c c c c c c c c c c c c c
e other ranges are too low or too high and do not reflect the average person’scomfo
c c c c c c c c c c c c c c c c
rt zone.
c
4. A homeless adult patient presents to the emergency department. The nu
c c c c c c c c c c
rse obtains the following vital signs: temperature 94.8° F, blood pressure
c c c c c c c c c c
106/56, apical pulse 58, and respiratory rate 12. Which vital sign should thenur
c c c c c c c c c c c c c
se address immediately?
c c
a. Respiratory rate c
3
b. Temperature
