ATI 206A Final Exam Summer
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Free ATI 206A Final Exam Summer Questions
A charge nurse is providing an in-service to a group of nursing staff about the components of a health record. Which of the following information should the nurse include? (Select All that Apply.)
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Driver's license
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Immunizations
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Financial status
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Allergies
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Medical history
Explanation
Explanation:
Correct Answer: (B) Immunizations, (D) Allergies, (E) Medical history
A client's health record is composed of clinically relevant information used to guide safe and effective care, including immunization records, documented allergies, and past medical history — all of which directly inform clinical decision-making.
Why Other Options are Incorrect:
A. Driver's license — This is a form of personal identification, not a clinical component of the health record.
C. Financial status — This is administrative/billing information and is not part of the clinical health record components used to guide care.
A nurse is discussing probable signs of pregnancy with a newly licensed nurse. Which of the following terms should the nurse use to describe the movement of the fetus felt by the provider after placing upward pressure on the cervix?
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Goodell's sign
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Ballottement
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Lightening
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Chadwick's sign
Explanation
Explanation:
Correct Answer: (B) Ballottement
Ballottement refers to the rebound movement of the fetus felt by the examiner when the fetus is pushed upward through the cervix and vaginal canal and then bounces back, indicating a probable sign of pregnancy.
Why Other Options are Incorrect:
A. Goodell's sign — This refers to softening of the cervix, a different probable sign of pregnancy.
C. Lightening — This refers to the descent of the fetal head into the pelvis, typically occurring near the end of pregnancy.
D. Chadwick's sign — This refers to the bluish discoloration of the cervix and vagina due to increased vascularity during pregnancy.
A nurse in the emergency department is caring for a client who appears shaky, pale, clammy, and is tachycardic. The client states, "I think I'm having an anxiety attack and need some medication." Which of the following is an appropriate action for the nurse to take?
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Establish IV access.
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Activate the Rapid Response Team.
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Check a fingerstick blood glucose level.
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Administer an anti-anxiety medication.
Explanation
Explanation:
Correct Answer: (C) Check a fingerstick blood glucose level.
The client's symptoms — shakiness, pallor, diaphoresis, and tachycardia — closely mimic both anxiety and hypoglycemia. Before assuming the client's self-diagnosis is correct, the nurse should first rule out a potentially dangerous and easily correctable cause like hypoglycemia by checking blood glucose, as treating a low blood sugar as anxiety could delay critical intervention.
Why Other Options are Incorrect:
A. Establish IV access. — This may become necessary depending on findings, but it is not the most immediate diagnostic priority before understanding the underlying cause of symptoms.
B. Activate the Rapid Response Team. — This is premature without first gathering more assessment data to determine if the client's condition is truly emergent.
D. Administer an anti-anxiety medication. — Administering medication based solely on the client's self-diagnosis without first ruling out a physiological cause like hypoglycemia could be dangerous and is not an appropriate first action.
A nurse is assessing a client who has chronic hypertension. Which of the following complications should the nurse identify as a result of chronic hypertension?
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Increased susceptibility to infections
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Risk of hemorrhagic stroke
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Development of peripheral neuropathy
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Increased risk of osteoporosis
Explanation
Chronic hypertension causes progressive damage to blood vessel walls, weakening them over time and making them more susceptible to rupture. This significantly increases the client's risk of a hemorrhagic stroke, particularly when blood pressure spikes acutely.
Why the other options are incorrect:
A. Increased susceptibility to infections — This is not a recognized complication of chronic hypertension; hypertension does not directly compromise immune function.
C. Development of peripheral neuropathy — Peripheral neuropathy is more commonly associated with conditions like diabetes mellitus, not hypertension directly.
D. Increased risk of osteoporosis — Osteoporosis is linked to factors such as aging, hormonal changes, and calcium/vitamin D deficiency, not chronic hypertension.
A nurse is caring for a client who has diabetic ketoacidosis (DKA) and is manifesting Kussmaul breathing. Which of the following pathophysiological terms is related to Kussmaul breathing?
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Lipolysis
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Metabolic alkalosis
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Hyperglycemia
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Hypokalemia
Explanation
Explanation:
Correct Answer: (A) Lipolysis
In DKA, insulin deficiency leads to increased lipolysis (breakdown of fats) as the body seeks alternative energy sources, producing ketone bodies and resulting in metabolic acidosis. Kussmaul breathing is the body's compensatory respiratory response — deep, rapid breathing — attempting to eliminate excess CO2 and correct this acidosis, making lipolysis the underlying pathophysiological process driving this manifestation.
Why Other Options are Incorrect:
B. Metabolic alkalosis — DKA causes metabolic acidosis, not alkalosis; Kussmaul breathing is a compensatory response to acidosis, the opposite condition.
C. Hyperglycemia — While hyperglycemia is present in DKA, it is not the direct pathophysiological driver of Kussmaul breathing; the acid-base disturbance from ketone production is the more direct link.
D. Hypokalemia — Potassium imbalances are a concern in DKA but are not directly related to the mechanism causing Kussmaul breathing.
A nurse is planning care for a client who has substance induced depressive disorder. The nurse should identify that this disorder is characterized by which of the following criteria?
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Characterized by severe recurrent temper outbursts.
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The client's depression cannot be explained by another diagnosis or factor.
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Induced by sensitivity to hormonal fluctuations.
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Manifestations have been experienced for at least 2 years.
Explanation
Let me reconsider this question, as none of the listed options accurately describe substance-induced depressive disorder based on standard diagnostic criteria (which require evidence that the depressive symptoms developed during or soon after substance intoxication/withdrawal or medication exposure, and that the substance is capable of producing the symptoms).
Since the given options don't reflect this defining feature, I want to flag this rather than guess — could you confirm the exact answer choices from the image, or let me know if there's additional context I'm missing?
A nurse is caring for a client who is at 7 weeks of gestation and is experiencing vaginal bleeding. An ultrasound shows not all products of conception have passed, the cervix is closed, and there is no fetal heartbeat. The nurse should identify this as which of the following types of spontaneous abortion?
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Complete
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Inevitable
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Threatened
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Missed
Explanation
Explanation:
Correct Answer: (D) Missed
A missed abortion is characterized by fetal death (no fetal heartbeat) with retention of the products of conception in the uterus, and the cervix typically remains closed since no expulsion process has been initiated.
Why Other Options are Incorrect:
A. Complete — A complete abortion involves total expulsion of all products of conception, which is inconsistent with the ultrasound findings showing retained products.
B. Inevitable — An inevitable abortion is characterized by an open cervix with bleeding, indicating that pregnancy loss cannot be prevented, which does not match the closed cervix finding here.
C. Threatened — A threatened abortion involves vaginal bleeding with a closed cervix but a viable fetus with a detectable heartbeat, which contradicts the absence of fetal heartbeat in this scenario.
A nurse is providing care for a client who has diabetes mellitus. Which of the following laboratory findings indicates the client most likely to be diagnosed with diabetic ketoacidosis (DKA)?
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Serum bicarbonate less than 15
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Blood urea nitrogen (BUN) 18 mg/dL
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Serum sodium 140 mg/dL
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Arterial blood pH 7.46
Explanation
Correct Answer:
(A) Serum bicarbonate less than 15. DKA is characterized by metabolic acidosis resulting from the accumulation of ketone bodies; a low serum bicarbonate level (typically less than 15-18 mEq/L) reflects this acidosis and is a key diagnostic laboratory finding consistent with DKA.
Why the other options are incorrect:
B. Blood urea nitrogen (BUN) 18 mg/dL. This value is within the normal reference range and does not indicate a finding consistent with DKA.
C. Serum sodium 140 mg/dL. This value is within the normal reference range for sodium and is not a diagnostic indicator of DKA.
D. Arterial blood pH 7.46. This value is within the normal range (7.35–7.45, slightly high/alkalotic) and is the opposite of what would be expected in DKA, which causes acidosis (a low, not normal or high, pH).
A school nurse and teacher collaborate about an adolescent who has a developmental delay about noticing a recent change in the child's behavior, noting that they have become disengaged in class, do not appear to have a group of friends, and make negative self-comments. Which of the following recommendations should the nurse present to the child's parents to address these concerns?
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Recommend that the child be transferred to a different school.
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Scheduling routine sessions with the school counselor.
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Tell the parents that this is expected part of development in adolescent years and is not concerning at this time.
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Engaging the client in an organized school activity such as a club or organization.
Explanation
Explanation:
Correct Answer: (B) Scheduling routine sessions with the school counselor.
Given the noted behavioral changes — disengagement, social isolation, and negative self-talk — connecting the adolescent with a school counselor provides consistent, professional support to address underlying emotional or social concerns and monitor the child's well-being over time.
Why Other Options are Incorrect:
A. Recommend that the child be transferred to a different school. — This is an extreme, premature action that does not address the underlying emotional or social concerns and could be disruptive without clear justification.
C. Tell the parents that this is expected and not concerning at this time. — This dismisses legitimate warning signs (disengagement, social isolation, negative self-comments) that warrant further evaluation and support, especially in a child with a developmental delay.
D. Engaging the client in an organized school activity such as a club or organization. — While social engagement can be beneficial, it does not address the deeper behavioral changes as directly or comprehensively as professional counseling support.
A nurse is caring for a client who is pregnant and asks the nurse about the option of abortion. Which of the following responses should the nurse make?
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"There are alternatives to abortion if you do not wish to raise a child."
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"Before you make such an important decision, it is important to consider the reasons not to abort a fetus."
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"There are resources available for people who are considering abortion, and I can help you access them."
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"If there is a developmental concern, we can perform some testing to see if the fetus is healthy."
Explanation
This response is nonjudgmental and supportive, providing the client with factual information and access to resources while respecting her autonomy to make her own informed decision without imposing the nurse's personal views.
Why the other options are incorrect:
A. "There are alternatives to abortion if you do not wish to raise a child." — This response is presumptive and subtly steers the client toward a particular choice rather than remaining neutral and supportive of her own decision-making.
B. "Before you make such an important decision, it is important to consider the reasons not to abort a fetus." — This is judgmental and imposes the nurse's personal bias, which is inappropriate and unprofessional in this context.
D. "If there is a developmental concern, we can perform some testing to see if the fetus is healthy." — This response does not address the client's actual question about abortion and instead redirects to an unrelated topic.
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