ATI PN 112 Final Exam 12/25
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Free ATI PN 112 Final Exam 12/25 Questions
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud’s phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
- “I will keep my house at a cool temperature.”
- “I will try to anticipate and avoid stressful situations.”
- “I will complete the smoking cessation program I started.”
- “I will wear gloves when removing food from the freezer.”
Explanation
Explanation
Raynaud’s phenomenon is triggered by exposure to cold and emotional stress, which cause vasospasm and decreased blood flow to the extremities. Clients should be taught to keep their environment warm to reduce the risk of attacks. Avoiding stress, stopping smoking, and protecting the hands from cold exposure with gloves are all appropriate preventive measures. Keeping the house cool increases the likelihood of vasoconstriction and symptom onset.Correct Answer Is:
A. “I will keep my house at a cool temperature.”A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?
- Tachycardia
- Muscle hypotonicity
- Diarrhea
- Positive Chvostek’s sign
Explanation
Explanation
A calcium level of 11.4 mEq/L indicates hypercalcemia. Elevated calcium levels reduce neuromuscular excitability, leading to muscle weakness, decreased muscle tone, and diminished deep tendon reflexes. Clients may also experience fatigue and lethargy. Diarrhea and a positive Chvostek’s sign are associated with hypocalcemia, while tachycardia is not a typical finding of hypercalcemia.Correct Answer Is:
B. Muscle hypotonicityMedical History
Client reports falling and hitting their head and right shoulder after slipping on a wet floor yesterday. Denies loss of consciousness. Complains of pain in right shoulder. Has taken both Tylenol and ibuprofen for pain with minimal relief obtained. Stayed up entire night playing video games yesterday to distract self from pain. Reports intermittent nausea and vomiting.
Nurses' Notes
0900:
Reports pain in right shoulder. Limited range of motion noted. Rates pain as 7 on a scale from 0 to 10. Denies numbness and tingling in arm. No swelling or bruising over the shoulder. Fingers warm with capillary refill time less than 3 seconds, sensation intact. Drowsy. Oriented to person, place, and time. Irritable and restless at times. PERRLA. Glasgow score of 15. No hematomas noted on head. No nausea or vomiting at this time.
1000:
Continues to report pain in right shoulder. Increased from 7 to 8 on 0 to10 pain scale. Increased drowsiness noted. Glasgow unchanged.
Vital Signs
Temp: 37.6° C (99.6° F) oral (expected reference range for adults: 36 to 38°C (96.8 to 100.4°F)
Heart rate: 76/min and regular (expected reference range for adults: 60 to 100/min)
Respiratory rate: 20/min even and unlabored (expected reference range for adults: 12 to 20/min)
Blood pressure: 112/70 mm Hg in left arm (expected reference range for adults: less than 120/80 mm Hg)
Pulse oximetry on room air: 98% (expected reference range for adults: greater than or equal to 95%)
A nurse is caring for a client who has recently fallen. Complete the following sentence by using the list of options.
The nurse should first address the client’s ________ followed by the client’s ________.
- Capillary refill time less than 3 seconds / Temperature
- Limited range of motion / Blood pressure
- Drowsiness / Pain in the right shoulder
- Limited range of motion / Temperature
Explanation
Explanation
Following a fall with head impact, neurological status takes priority. The client demonstrates increasing drowsiness, which may indicate evolving intracranial injury despite a stable Glasgow Coma Scale score and normal vital signs. Neurologic changes must be addressed first due to the risk of rapid deterioration. Once neurological safety is ensured, the nurse should address the client’s right shoulder pain, which is increasing and affects comfort and mobility but is not immediately life-threatening.Correct Answer Is:
C. Drowsiness / Pain in the right shoulderA nurse finds a client who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and reporting feeling lightheaded and shaky. Which of the following complications should the nurse suspect?
- Ketoacidosis
- Hyperglycemia
- Hypoglycemia
- Nephropathy
Explanation
Explanation
Hypoglycemia is characterized by adrenergic symptoms caused by activation of the sympathetic nervous system. These include sweating, tachycardia, shakiness, lightheadedness, anxiety, and hunger. Clients with type 1 diabetes are especially at risk due to insulin use. Prompt recognition is critical because untreated hypoglycemia can progress to confusion, seizures, loss of consciousness, and death.Correct Answer Is:
C. HypoglycemiaMedication Administration Record
Naltrexone 50mg PO once daily
Fluoxetine 20mg PO every morning
Diagnostic Results
Hepatitis Viral Study (HAA) positive (expected reference range: negative)
Sodium 131 mEq/L (expected reference range 136 to 145 mEq/L
Calcium 9.5 mg/dL (expected reference range 9 to 10.5 mg/dL)
BUN 11 mg/dL (expected reference range 10 to 20 mg/dL)
FBS 82 mg/dL (expected reference range 74 to 106 mg/dL)
Hct 44% (expected reference range 37% to 52%)
Hgb 14 g/dL (expected reference range 12 to 18 g/dL)
Medical History
Client has been hospitalized three times within the past 12 months. Client shows marked emotional lability and difficulty controlling impulses. Client admits to having multiple sexual partners and denies use of condoms. History of total abdominal hysterectomy 10 years ago. Client also acknowledges spending a lot of money lately and is not sure how to pay for current bills. Client admits to using self-mutilating behaviors (cutting) in the past to soothe them when feeling anxious - no evidence of recent self-mutilation. Client has recently suffered the loss of their remaining living parent and has increased the use of alcohol and recreational intravenous drugs to numb the pain.
Nurses' Notes
Skin warm and dry. Sclera bloodshot. Client is unsteady on their feet, restless and tense. Admits to drinking "a lot of whiskey" within last 24 hrs. Presence of alcohol noted on breath. Asking for "my nerve" pill. Evidence of old healed scratches/cuts noted on arms and legs. Client has several
tattoos on back, arms, and lower abdomen. States, "I don't have any money to pay for this!" When asked about living family members, states, "everyone is dead, life stinks."
A nurse is caring for a client who has borderline personality disorder (BPD).
The nurse completed a review of the client's electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)
- Hepatitis Viral Study (HAA) results
- BUN level
- Frequency of hospitalizations
- Financial status
- Increased use of mood-altering substances
- Sexual behaviors
- Sodium level
- Loss of parent
- I. Hgb level
Explanation
Explanation
Explanation of Correct Answers:A. Hepatitis Viral Study (HAA) results
A positive hepatitis viral study requires immediate follow-up because it indicates an active or prior viral hepatitis infection. This is especially concerning given the client’s intravenous drug use, which increases the risk of transmission and liver injury. Prompt follow-up is needed for infection control, further diagnostic evaluation, patient education, and coordination of appropriate medical treatment.
E. Increased use of mood-altering substances
The client’s increased use of alcohol and intravenous drugs requires immediate follow-up due to the high risk of overdose, withdrawal, impaired judgment, and worsening mental health symptoms. Substance use also increases the risk of self-harm, unsafe behaviors, and medical complications. Early intervention is essential to ensure safety and initiate appropriate substance-use treatment and monitoring.
F. Sexual behaviors
The client’s report of multiple sexual partners without condom use requires immediate follow-up because it places the client at high risk for sexually transmitted infections, including HIV and hepatitis. This concern is heightened by the positive hepatitis study and substance use. The nurse must address risk reduction, screening, and education to prevent further health complications.
G. Sodium level
The sodium level of 131 mEq/L indicates hyponatremia, which can lead to neurological symptoms such as confusion, seizures, and altered mental status if it worsens. Given the client’s psychiatric condition, substance use, and current instability, this abnormal value requires prompt assessment and intervention to prevent complications.
H. Loss of parent
The recent loss of the client’s remaining living parent requires immediate follow-up due to its significant emotional impact. In a client with borderline personality disorder, grief can intensify impulsivity, substance use, emotional instability, and suicidal risk. The nurse must assess coping, safety, and the need for emotional and mental health support.
Correct Answer Is:
A. Hepatitis Viral Study (HAA) resultsE. Increased use of mood-altering substances
F. Sexual behaviors
G. Sodium level
H. Loss of parent
A nurse is collecting data from a 6-year-old child at a well-child visit. Which of the following statements by the child’s parent should the nurse report to the provider?
- “My child often cheats when we play board games.”
- “Sometimes my child has temper tantrums.”
- “The teacher says my child has to squint to see the board.”
- “My child has recently lost both front top teeth.”
Explanation
Explanation
Squinting to see the board is a potential sign of a vision problem, such as myopia, which can interfere with learning and school performance. At 6 years old, children should have adequate visual acuity for classroom activities. This finding requires further evaluation by the provider and likely referral for a formal vision screening or eye examination.Correct Answer Is:
C. “The teacher says my child has to squint to see the board.”A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- “You’ll have to remove metal objects such as watches and body jewelry.”
- “Unlike an x-ray, the MRI allows you to move around a bit.”
- “Your exposure to radiation will be minimal.”
- “You will not be able to talk to the technician during the procedure.”
Explanation
Explanation
MRI uses a powerful magnetic field, so all metal objects must be removed to prevent injury and avoid interference with image quality. Clients must remain still during the procedure, and MRI does not use ionizing radiation. Communication with the technician is maintained throughout the scan via an intercom system, making the other statements incorrect.Correct Answer Is:
A. “You’ll have to remove metal objects such as watches and body jewelry.”A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- Discourage the client from ambulating.
- Keep the client's leg in a dependent position.
- Use a hair dryer on a hot setting to dry the cast.
- Perform a neurovascular check of the lower extremities.
Explanation
Explanation
After cast application, the priority nursing action is to monitor for neurovascular compromise, which can occur due to swelling and pressure within the cast. Neurovascular checks include assessing circulation, sensation, movement, color, temperature, capillary refill, pulses, and pain. Early detection of impaired perfusion or nerve compression helps prevent serious complications such as compartment syndrome or permanent tissue damage.Correct Answer Is:
D. Perform a neurovascular check of the lower extremities.A nurse is preparing to administer an ophthalmic solution to a client. Which of the following actions should the nurse take?
- Bring the dropper from below the client’s eye to instill the solution.
- Instill the drops into the inner canthus.
- Ask the client to look down when instilling the solution.
- Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.
Explanation
Explanation
When administering ophthalmic medications, the nurse should pull down the lower eyelid to expose the conjunctival sac and hold the dropper approximately 1 to 2 cm above it. This technique prevents contamination of the dropper tip and ensures accurate delivery of the medication into the conjunctival sac, where it can be absorbed effectively. The client should be instructed to look upward, not downward, during instillation.Correct Answer Is:
D. Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.A nurse is reinforcing teaching with a client who is lactose intolerant. Which of the following statements should the nurse include in the teaching?
- “You should increase the fiber in your diet.”
- “You should decrease the amount of vitamin D in your diet.”
- “You should decrease the dairy products in your diet.”
- “You should increase the calories in your diet.”
Explanation
Explanation
Lactose intolerance occurs when the body lacks sufficient lactase to digest lactose found in dairy products. Reducing or avoiding dairy helps prevent symptoms such as bloating, diarrhea, abdominal pain, and gas. Clients can choose lactose-free dairy products or alternative sources of calcium and vitamin D to maintain adequate nutrition while minimizing gastrointestinal discomfort.Correct Answer Is:
C. “You should decrease the dairy products in your diet.”How to Order
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