Download ATI FUNDAMENTAL 3 -2024/2025- EXAM ACTUAL QUESTIONS AND CORRECT ANSWERS ALREADY GRADED A and more Exams Nursing in PDF only on Docsity!
ATI FUNDAMENTAL 3 - 2024/2025- EXAM
ACTUAL QUESTIONS AND CORRECT
ANSWERS ALREADY GRADED A+
GUARANTEED PASS
A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies. A, B, C, & E are correct Help the client see the benefits of their actions. The nurse should plan to assist the client to recognize the benefits of their health- promoting actions while also overcoming barriers to implementing actions. Identify the client's support systems. The nurse should plan to collect information about who can help the client change unhealthy behaviors, and then suggest steps to have friends and family to become involved and supportive. Suggest and recommend community resources.
The nurse should plan to promote the client's use of any available community or online resources that can help the client progress toward meeting set goals. Teach stress management strategies. The nurse should plan to teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders. Devise and set goals for the client. The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis. B. Tell the client to have a TB skin test every 2 years. C. Determine the client's health risks. D. Teach the client about exercise recommendations. C. Determine the client's health risks. The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn? A."I will not look at my incision after the surgery." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "I can't remember what my doctor told me about the surgery." C. "Can you tell me about how long the surgery will take?"
education for the client on preexisting knowledge. The second action the ostomy nurse should take using the nursing process is to plan to use instructional materials to educate the client about colostomy care. The third action the ostomy nurse should take using the nursing process is implementation. The ostomy nurse demonstrates how to care for the colostomy. The fourth action the ostomy nurse should take using the nursing process is evaluation. The ostomy nurse evaluates the client's understanding of how to care for their colostomy. NCLEX Connection: Reduction of Risk Potential, Therapeutic Procedures The ostomy nurse is educating the client about the new colostomy. Sort the nursing actions into the cognitive, affective, or psychomotor domains of learning. Cognitive - Affective - Psychomotor- The ostomy nurse encourages the client to share their feelings about their colostomy. The client performs a return demonstration of emptying the colostomy pouch. The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet. Cognitive - The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet. Affective - The ostomy nurse encourages the client to share their feelings about their colostomy. Psychomotor- The client performs a return demonstration of emptying the colostomy pouch. When taking actions, the ostomy nurse is using the cognitive domain of learning when providing the client with a list of foods they can eat and foods they should avoid in their diet. The ostomy nurse is encouraging the client to ask questions to
promote understanding about the teaching. The ostomy nurse is using the affective domain of learning when encouraging the client to share their feelings about their colostomy. The affective domain promotes the expression of feelings and encourages support from others. The ostomy nurse is using the psychomotor domain of learning when demonstrating how to empty the ostomy pouch and asking the client to perform a return demonstration of the procedure. The psychomotor domain of learning involves performing a physical task. The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the following actions by the client indicates that psychomotor learning has taken place? A. The client states how often the ostomy pouch should be emptied. B. The client demonstrates emptying the ostomy pouch. C. The client writes the steps of how to empty the ostomy pouch on a piece of paper. D. The client states they understand how to empty their ostomy pouch. B. The client demonstrates emptying the ostomy pouch. When evaluating outcomes, the ostomy nurse should identify that the client demonstrating that they can empty the ostomy pouch indicates psychomotor learning has taken place. The psychomotor domain of learning involves performing a physical task. The ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions about their diet. B. Ask the client to list foods to include in their diet. C. Encourage the client to fill out an evaluation form about how the nurse presented the information about diet. D. Ask the client if they have additional resources for further instruction about their new diet. B. Ask the client to list foods to include in their diet.
The nurse should identify that physiological changes that occur with aging can include decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which can cause wrinkles and dry, thin, transparent skin. Other physiological changes that occur with aging can include decreased saliva production, making xerostomia (dry mouth) a common problem. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day." D. is correct - "I keep forgetting which medications I have taken during the day." The nurse should identify that the greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue is to assist the client to implement safe medication strategies. Assist the client to use a pill organizer to help them remember to take their medications and to keep a list of all current medications. "I spent my whole life dreaming about retirement, and now I wish I had my job back." The client is at risk for social isolation and loss of independence because of retirement. However, another issue is the priority. "It's been so stressful for me to have to depend on my child to help around the house." The client is at risk for loss of independence and reduced self-esteem due to dependence upon their child. However, another issue is the priority. "I just heard my friend Al died. That's the third one in 3 months."
The client is at risk for social isolation due to the loss of a friend. However, another issue is the priority. A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following should the nurse plan to include in the presentation? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal vaccination C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test B, C, D, & E B. Pneumococcal vaccination The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. C. Yearly eye examination The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. D. Periodic mental health screening The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients.
"Exercise every day to increase appetite." The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite. "Eat your meals in front of the television." The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake. "Eat three large meals a day." The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake. A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation. A, C, D, & E The nurse should identify that older adults should increase protein intake to increase muscle mass and improve wound healing, increase calcium intake to reduce the risk for osteoporosis, limit sodium intake to reduce the risk for edema and hypertension, and increase fiber intake to prevent constipation. A nurse in a provider's office is testing the cranial nerves during a head and neck examination. Which of the following cranial nerves are both sensory and motor? (Select all that apply.) A. Cranial Nerve II (Optic) B. Cranial Nerve V (Trigeminal)
C. Cranial Nerve VII (Facial) D. Cranial Nerve VIII (Auditory) E. Cranial Nerve XI (Spinal accessory) B & C Cranial Nerve V (Trigeminal) Cranial nerve V, the trigeminal nerve provides sensory input for the face as well as movement of the jaw; therefore, it is both sensory and motor. Cranial Nerve VII (Facial) Cranial nerve VII, the facial nerve allows for facial expression and taste, therefore, it is both sensory and motor. Cranial Nerve II (Optic) During an examination of the head and neck, the nurse should recognize that Cranial Nerve II, the optic nerve whose function is visual acuity is sensory only. Cranial Nerve VIII (Auditory) Cranial nerve VIII, the auditory nerve provides for hearing and thus, it is sensory only. Cranial Nerve XI (Spinal accessory) Cranial Nerve XI, Spinal accessory, provides for movement of the head and shoulders and is motor only. A nurse is examining a client's head and neck lymph nodes. Match the name of the lymph node with the location of the lymph node. Submental Postauricular Nodes Anterior Cervical Nodes Tonsillar Nodes Occipital Nodes
The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline. Visualizing the thyroid on inspection of the neck. An average size thyroid gland is not visible on inspection. Visualization of the thyroid gland could indicate a thyroid disorder. Hearing a bruit when auscultating the thyroid. A bruit indicates increase blood flow and can indicate hyperthyroidism. A nurse is preparing to inspect the ears, nose, mouth, and throat of a client. Which of the following equipment does the nurse need? (Select all that apply._) A. Ophthalmoscope B. Tongue blade C. Penlight D. Gauze Square E. Stethoscope B, C, & D Gauze square A gauze square to grasp the tongue during the examination. Penlight A penlight to examine the color size, position and texture of the tongue. Tongue blade When examining the ears, mouth a nose of a client, the nurse needs a tongue blade to examine the client's tongue on all sides and the floor of the mouth. Ophthalmoscope An ophthalmoscope is used to examine a client's eyes. Stethoscope A stethoscope is used when the nurse is performing auscultation.
A nurse is performing auditory screening for a client. Match the name of the test with the technique the nurse should use. Rinne Test ( Air Conduction) Weber's Test (Bone Conductivity) Whisper Test The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. The nurse places a vibrating tuning fork on top of the head and asks the client if the sound is best in the left or right ear. Whisper Test - The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. Rinne Test (Air Conduction) - The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. Weber's Test (Bone Conductivity) - The nurse places a vibrating tuning fork on top of the head and asks the client if the sound is best in the left or right ear. The nurse uses the whisper test to assess high-frequency hearing in both ears. Abnormal findings include the client asking the nurse to repeat the words and/or the client is unable to repeat the words. If the client has difficulty with the Whisper test, the nurse proceeds to the Rinne test and Weber's test. During the Rinne test, the nurse places a vibrating tuning fork against the client's mastoid bone and measures the length of time the client can hear the sound. An expected finding is that the client can hear air- conducted sounds twice as long as bone conducted
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch." C & E "Clench your teeth." Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench their teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. "Tell me when you feel a touch." Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when they feel a gentle touch on the face from a wisp of cotton. "Raise your eyebrows." Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise their eyebrows, puff out the cheeks, and perform other facial movements. "Tell me what you can taste." Testing the sensory function of cranial nerve VII, the facial nerve, involves testing the mouth for taste sensations. "Close your eyes." The first step of testing cranial nerve I, the olfactory nerve, is to have the client close their eyes prior to testing the sense of smell
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape. B, D, & E Use the light to visualize the tympanic membrane in a cone shape. Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle. Make sure the speculum does not touch the ear canal. The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. Insert the speculum slightly down and forward. Inserting the speculum slightly down and forward follows the natural shape of the ear canal. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). Insert the speculum 1 to 1.5 cm (0.4 to 0.6 in). Pull the auricle down and back. The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years. The first action that should be taken using the nursing process is assessment. Talk with the client first to determine what risk factors the client might have before initiating the health promotion and disease prevention measures.
Each eye has its own visual acuity, which includes both numbers. A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums C, D, & E Thickened eardrums Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals. Glare intolerance Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. Tooth loss Tooth loss and gum disease are common in older adults. Reddened gums Expect an older adult's gums to be pale. Lowered vocal pitch Expect an older adult's vocal pitch to rise. A nurse is examining the breast of a female young adult client. The nurse should determine that which of the following are expected findings? (Select all that apply.) A. The client's nipples are inverted. B. The client has a dimple on the left breast.
C. The client's left breast is smaller than the right breast. D. The client's areolas are oval shaped. E. The underlying veins in the breast are visible. C, D, & E The underlying veins in the breast are visible. The veins can be visualized for client who is thin. The client's areolas are oval-shaped. The client's areolas can be either round or oval-shaped. The client's left breast is smaller than the right breast. One breast larger than the other is a common, expected finding. The client's nipples are inverted. An expected finding is that the client's nipples are everted. The nurse should determine whether the client has a lifetime history of nipple inversion because a recent inversion of the nipple can indicate an underlying mass. The client has a dimple on the left breast. A dimple can also indicate an underlying mass. A nurse is examining a client's chest. Matching the name of the vertical chest landmarks with their location. Midaxillary Line Anterior Axillary Line Midsternal Line The Vertebral Line Over the center of the sternum Extends down from the anterior axillary fold Runs down from the apex of the axillary
