ATI Comprehensive Exam II Latest Containing 100 Questions
with Answers and Rationale
1. In a child with suspected coarctation of the aorta, the nurse would expect to
find
The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta,
causes increased flow to the upper extremities (increased pressure and pulses)
2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of
the following actions by
The correct answer is C: Confine the percussion to the rib cage area Percussion
(clapping) should be only done in the area of the rib cage.
3. A client was admitted to the psychiatric unit with major depression after a
suicide attempt. In addition to feeling sad and hopeless, the nurse would
assess for
The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor
retardation or psychomotor agitation, chronic generalized or local pain, sleep
disturbances, disturbances in appetite, gastrointestinal complaints and impaired
libido.
4. A victim of domestic violence states to the nurse, "If only I could change and be
how my companion wants me to be, I know things would be different." Which
would be the best response by the nurse?
The correct answer is D: "Batterers lose self-control because of their own internal
reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s
behavior will not cause the abuser to become nonviolent.
5. A nurse is to present information about Chinese folk medicine to a group of
student nurses. Based on this cultural belief, the nurse would explain that
illness is attributed to the
The correct answer is B: Yin, the negative force that represents darkness, cold,
and emptiness. Chinese folk medicine proposes that health is regulated by the
opposing forces of yin and yang. Yin is the negative female force characterized by
darkness, cold and emptiness. Excessive yin predisposes one to nervousness.
6. A polydrug user has been in recovery for 8 months. The client has began
skipping breakfast and not eating regular dinners. The client has also started
frequenting bars to "see old buddies." The nurse understands that the client’s
behavior is a warning sign to indicate that the client may be
The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is
important for clients to acknowledge that relapse is a possibility and to identify
early signs of relapse.
7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid
,Type sits alone alertly watching the activities of clients and staff. The client is
hostile when approached and asserts that the doctor gives her medication to
control her mind. The client's behavior most likely indicates
The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social
isolation. Her psychiatric diagnosis and her idea about the purpose of medication
suggests altered thinking processes.
8. A client is admitted with the diagnosis of meningitis. Which finding would the
nurse expect in assessing this client?
The correct answer is B: Flexion of the hip and knees with passive flexion of the
neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of
the neck; a positive Kernig’s sign—inability to extend the knee to more than 135
degrees, without pain behind the knee, while the hip is flexed usually establishes
the diagnosis of meningitis.
9. Post-procedure nursing interventions for electroconvulsive therapy include
The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy
and confused. The nurse remains with the client until the client is oriented and
able to engage in self care.
10. The nurse is talking to parents about nutrition in school aged children.
Which of the following is the
The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These
include heredity, sedentary lifestyle, social and cultural factors and poor
knowledge of balanced nutrition.
11. The nurse assesses a client who has been re-admitted to the psychiatric
inpatient unit for schizophrenia. His symptoms have been managed for several
months with fluphenazine (Prolixin). Which should be a focus of the first
assessment?
A) Stressors in the home
The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the
symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.
12. The nurse admits a client newly diagnosed with hypertension. What is the
best method for assessing the blood pressure?
The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian
artery may be stenosed, causing a false high in that arm.
13. The nurse is caring for a client who has developed cardiac tamponade. Which
finding would the nurse anticipate?
The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous
blood cannot flow into the heart. As a result, venous pressure rises and the neck
veins become distended.
, 14. At the geriatric day care program a client is crying and repeating "I want to go
home. Call my daddy to come for me." The nurse should
The correct answer is C: Give the client simple information about what she will be
doing. The distressed disoriented client should be gently oriented to reduce fear
and increase the sense of safety and security. Environmental changes provoke
stress and fear.
15. When teaching adolescents about sexually transmitted diseases, what should
the nurse emphasize that is the most common infection?
The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this
country. Prevention is similar to safe sex practices taught to prevent any STD: use
of a condom and spermicide for protection during intercourse.
16. A 38 year-old female client is admitted to the hospital with an acute
exacerbation of asthma. This is her third admission for asthma in 7 months.
She describes how she doesn't really like having to use her medications all
the time. Which explanation by the nurse best describes the long-term
consequence of uncontrolled airway inflammation?
The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially
returns to normal, chronic under-treated asthma can lead to lung remodeling and
permanent changes in lung function. Increased bronchial vascular permeability
leads to chronic airway edema which leads to mucosal thickening and swelling of
the airway. Increased mucous secretion and viscosity may plug airways, leading to
airway obstruction. Changes in the extracellular matrix in the airway wall may
also lead to airway obstruction. These long-term consequences should help you to
reinforce the need for daily management of the disease whether or not the
patient "feels better".
17. The mother of a 15 month-old child asks the nurse to explain her child's lab
results and how they show her child has iron deficiency anemia. The nurse's
best response is
The correct answer is B: "Your child has less red blood cells that carry oxygen."
The results of a complete blood count in clients with iron deficiency anemia will
show decreased red blood cell levels, low hemoglobin levels and microcytic,
hypochromic red blood cells. A simple but clear explanation is appropriate.
18. Privacy and confidentiality of all client information is legally protected. In
which of these situations would the nurse make an exception to this practice?
The correct answer is B: When the client threatens self-harm and harm to
others. Privacy and confidentiality of all client information is protected with
the exception of the client who threatens self harm or endangering the public.
19. At a well baby clinic the nurse is assigned to assess an 8 month-old child.
Which of these developmental achievements would the nurse anticipate that
the child would be able to perform?
The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without
support is 8 months.
20. First-time parents bring their 5 day-old infant to the pediatrician's office
because they are extremely concerned about its breathing pattern. The nurse
with Answers and Rationale
1. In a child with suspected coarctation of the aorta, the nurse would expect to
find
The correct answer is D: Bounding pulses in the arms
Coarctation of the aorta, a narrowing or constriction of the descending aorta,
causes increased flow to the upper extremities (increased pressure and pulses)
2. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of
the following actions by
The correct answer is C: Confine the percussion to the rib cage area Percussion
(clapping) should be only done in the area of the rib cage.
3. A client was admitted to the psychiatric unit with major depression after a
suicide attempt. In addition to feeling sad and hopeless, the nurse would
assess for
The correct answer is C: Psychomotor retardation or agitation
Somatic or physiologic symptoms of depression include: fatigue, psychomotor
retardation or psychomotor agitation, chronic generalized or local pain, sleep
disturbances, disturbances in appetite, gastrointestinal complaints and impaired
libido.
4. A victim of domestic violence states to the nurse, "If only I could change and be
how my companion wants me to be, I know things would be different." Which
would be the best response by the nurse?
The correct answer is D: "Batterers lose self-control because of their own internal
reasons, not because of what their partner did or did not do."
Only the perpetrator has the ability to stop the violence. A change in the victim’s
behavior will not cause the abuser to become nonviolent.
5. A nurse is to present information about Chinese folk medicine to a group of
student nurses. Based on this cultural belief, the nurse would explain that
illness is attributed to the
The correct answer is B: Yin, the negative force that represents darkness, cold,
and emptiness. Chinese folk medicine proposes that health is regulated by the
opposing forces of yin and yang. Yin is the negative female force characterized by
darkness, cold and emptiness. Excessive yin predisposes one to nervousness.
6. A polydrug user has been in recovery for 8 months. The client has began
skipping breakfast and not eating regular dinners. The client has also started
frequenting bars to "see old buddies." The nurse understands that the client’s
behavior is a warning sign to indicate that the client may be
The correct answer is A: headed for relapse
It takes 9 to 15 months to adjust to a lifestyle free of chemical use, thus it is
important for clients to acknowledge that relapse is a possibility and to identify
early signs of relapse.
7. At the day treatment center a client diagnosed with Schizophrenia - Paranoid
,Type sits alone alertly watching the activities of clients and staff. The client is
hostile when approached and asserts that the doctor gives her medication to
control her mind. The client's behavior most likely indicates
The correct answer is B: Social isolation related to altered thought processes
Hostility and absence of involvement are data supporting a diagnosis of social
isolation. Her psychiatric diagnosis and her idea about the purpose of medication
suggests altered thinking processes.
8. A client is admitted with the diagnosis of meningitis. Which finding would the
nurse expect in assessing this client?
The correct answer is B: Flexion of the hip and knees with passive flexion of the
neck. A positive Brudzinski’s sign—flexion of hip and knees with passive flexion of
the neck; a positive Kernig’s sign—inability to extend the knee to more than 135
degrees, without pain behind the knee, while the hip is flexed usually establishes
the diagnosis of meningitis.
9. Post-procedure nursing interventions for electroconvulsive therapy include
The correct answer is C: Remaining with client until oriented
Client awakens post-procedure 20-30 minutes after treatment and appears groggy
and confused. The nurse remains with the client until the client is oriented and
able to engage in self care.
10. The nurse is talking to parents about nutrition in school aged children.
Which of the following is the
The correct answer is C: Obesity
Many factors contribute to the high rate of obesity in school aged children. These
include heredity, sedentary lifestyle, social and cultural factors and poor
knowledge of balanced nutrition.
11. The nurse assesses a client who has been re-admitted to the psychiatric
inpatient unit for schizophrenia. His symptoms have been managed for several
months with fluphenazine (Prolixin). Which should be a focus of the first
assessment?
A) Stressors in the home
The correct answer is B: Medication compliance
Prolixin is an antipsychotic / neuroleptic medication useful in managing the
symptoms of Schizophrenia. Compliance with daily doses is a critical assessment.
12. The nurse admits a client newly diagnosed with hypertension. What is the
best method for assessing the blood pressure?
The correct answer is B: In both arms
Blood pressure should be taken in both arms due to the fact that one subclavian
artery may be stenosed, causing a false high in that arm.
13. The nurse is caring for a client who has developed cardiac tamponade. Which
finding would the nurse anticipate?
The correct answer is C: Distended neck veins
In cardiac tamponade, intrapericardial pressures rise to a point at which venous
blood cannot flow into the heart. As a result, venous pressure rises and the neck
veins become distended.
, 14. At the geriatric day care program a client is crying and repeating "I want to go
home. Call my daddy to come for me." The nurse should
The correct answer is C: Give the client simple information about what she will be
doing. The distressed disoriented client should be gently oriented to reduce fear
and increase the sense of safety and security. Environmental changes provoke
stress and fear.
15. When teaching adolescents about sexually transmitted diseases, what should
the nurse emphasize that is the most common infection?
The correct answer is B: Chlamydia
Chlamydia has the highest incidence of any sexually transmitted disease in this
country. Prevention is similar to safe sex practices taught to prevent any STD: use
of a condom and spermicide for protection during intercourse.
16. A 38 year-old female client is admitted to the hospital with an acute
exacerbation of asthma. This is her third admission for asthma in 7 months.
She describes how she doesn't really like having to use her medications all
the time. Which explanation by the nurse best describes the long-term
consequence of uncontrolled airway inflammation?
The correct answer is C: Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially
returns to normal, chronic under-treated asthma can lead to lung remodeling and
permanent changes in lung function. Increased bronchial vascular permeability
leads to chronic airway edema which leads to mucosal thickening and swelling of
the airway. Increased mucous secretion and viscosity may plug airways, leading to
airway obstruction. Changes in the extracellular matrix in the airway wall may
also lead to airway obstruction. These long-term consequences should help you to
reinforce the need for daily management of the disease whether or not the
patient "feels better".
17. The mother of a 15 month-old child asks the nurse to explain her child's lab
results and how they show her child has iron deficiency anemia. The nurse's
best response is
The correct answer is B: "Your child has less red blood cells that carry oxygen."
The results of a complete blood count in clients with iron deficiency anemia will
show decreased red blood cell levels, low hemoglobin levels and microcytic,
hypochromic red blood cells. A simple but clear explanation is appropriate.
18. Privacy and confidentiality of all client information is legally protected. In
which of these situations would the nurse make an exception to this practice?
The correct answer is B: When the client threatens self-harm and harm to
others. Privacy and confidentiality of all client information is protected with
the exception of the client who threatens self harm or endangering the public.
19. At a well baby clinic the nurse is assigned to assess an 8 month-old child.
Which of these developmental achievements would the nurse anticipate that
the child would be able to perform?
The correct answer is C: Sit without support
The age at which the normal child develops the ability to sit steadily without
support is 8 months.
20. First-time parents bring their 5 day-old infant to the pediatrician's office
because they are extremely concerned about its breathing pattern. The nurse
