ATI MED SURG PROCTORED EXAM

(Detail Solutions)

1. The nurse is attempting to prompt the patient to elaborate on the reports of

daytime fatigue. Which question should the nurse ask?

“Is there anything that you are stressed about right now that I should

a. know?”

b. “What reasons do you think are contributing to your fatigue?”

c. “What are your normal work hours?”

d. “Are you sleeping 8 hours a night?”

ANS: B

The question asking the patient what factors might be contributing to the

fatigue will elicit the best open-ended response. Asking whether the patient is

stressed and asking if the patient is sleeping 8 hours a night are closed- ended

questions eliciting simple yes or no responses. Asking about normal work

hours will elicit a matter-of- fact response and does not prompt the patient to

elaborate on the daytime fatigue or ask about the contributing reasons.

2. A nurse is conducting a nursing health history. Which component will the

nurse address?

a. Nurse’s concerns

b. Patient expectations

c. Current treatment orders

d. Nurse’s goals for the patient

ANS: B

Some components of a nursing health history include chief concern, patient

expectations, spiritual health, and review of systems. Current treatment

orders are located under the Orders section in the patient’s chart and are not

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a part of the nursing health history. Patient concerns, not nurse’s concerns,

are included in the database.

Goals that are mutually established, not nurse’s goals, are part of the nursing

care plan.

3. While the patient’s lower extremity, which is in a cast, is assessed, the

patient tells the nurse about an inability to rest at night. The nurse disregards

this information, thinking that no correlation has been noted between having

a leg cast and developing restless sleep. Which action would have been best

for the nurse to take?

a. Tell the patient to just focus on the leg and cast right now.

b. Document the sleep patterns and information in the patient’s chart.

c. Explain that a more thorough

assessment will be needed next shift.

Ask the patient about usual sleep

patterns and the onset of having

d. difficulty resting.

ANS: D

The nurse must use critical thinking skills in this situation to assess first in

this situation. The best response is to gather more assessment data by asking

the patient about usual sleep patterns and the onset of having difficulty

resting. The nurse should assess before documenting and should not ignore

the patient’s report of a problem or postpone it till the next shift.

4. The nurse begins a shift assessment by examining a surgical dressing that is

saturated with serosanguineous drainage on a patient who had open abdominal

surgery yesterday (or 1 day ago). Which type of assessment approach is the

nurse using?

a. Gordon’s Functional Health Patterns

b. Activity-exercise pattern assessment

c. General to specific assessment

d. Problem-oriented assessment

ANS: D

The nurse is not doing a complete, general assessment and then focusing on

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specific problem areas. Instead, the nurse focuses immediately on the problem

at hand (dressing and drainage from surgery) and performs a problem-oriented

assessment. Utilizing Gordon’s Functional Health Patterns is an example of a

structured database-type assessment technique that includes 11 patterns to

assess. The nurse in this question is performing a specific problem-oriented

assessment approach, not a general approach. The nurse is not performing an

activity-exercise pattern assessment in this question.

5. Which statement by a nurse indicates a good understanding about the

differences between data validation and data interpretation?

a. “Data interpretation occurs before data validation.”

b. “Validation involves looking for patterns in professional standards.”

c. “Validation involves comparing data

with other sources for accuracy.” “Data

interpretation involves discovering

patterns in professional

d. standards.”

ANS: C

Validation, by definition, involves comparing data with other sources for

accuracy. Data interpretation involves identifying abnormal findings,

clarifying information, and identifying patient problems. The nurse should

validate data before interpreting the data and making inferences. The nurse is

interpreting and validating patient data, not professional standards.

6. Which scenario best illustrates the nurse using data validation when

making a nursing clinical decision for a patient?

The nurse determines to remove a

wound dressing when the patient

reveals the time of the last dressing

change and notices old and new

a. drainage.

The nurse administers pain medicine due at

1700 at 1600 because the

b. patient reports increased pain and the

family wants something done.

The nurse immediately asks the health care provider for an order of

c. potassium when a patient reports leg cramps.

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