ATI Med-Surg Proctored Exam

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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 th... at 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 1 orders are located under the Orders section in the patient’s chart and are not 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 2 The nurse is not doing a complete, general assessment and then focusing on [Show More]

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