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