ATI HEALTH ASSESSMENT FINAL EXAM ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS (ALREADY GRADED A+) | LATEST VERSION 2026 | PROFESSOR VERIFIED
Question 1
When using a Snellen eye chart to assess a client's distance vision, at what distance should the
nurse instruct the client to stand from the chart?
A) 10 feet
B) 14 inches
C) 15 feet
D) 20 feet
E) 30 feet
Correct Answer: D) 20 feet
Rationale: The Snellen eye chart is the standard tool for measuring distance visual acuity.
The standard testing distance is 20 feet (6 meters). The results are recorded as a fraction,
where the numerator is the distance the client stands from the chart (20), and the
denominator is the distance at which a person with normal vision can read that specific
line.
Question 2
A nurse is preparing to assess a client's near vision. Which tool should the nurse use, and at what
distance should it be held?
A) Snellen chart at 20 feet
B) Rosenbaum chart at 14 inches
C) Snellen chart at 14 inches
D) Rosenbaum chart at 20 feet
E) Ishihara plates at 30 inches
Correct Answer: B) Rosenbaum chart at 14 inches
Rationale: The Rosenbaum eye chart (or a Jaeger card) is used to evaluate near vision and
screen for presbyopia. It should be held approximately 14 inches (35 cm) from the client's
eyes. Testing each eye individually and then both together provides an accurate assessment
of the client's functional near vision.
Question 3
Which of the following factors is considered an internal risk factor that affects a patient's ability
to protect themselves from injury?
A) Use of a generic brand of soap
B) Cognitive and sensory awareness
C) The brand of the hospital bed
D) The temperature of the hallway
E) The presence of a roommate
Correct Answer: B) Cognitive and sensory awareness
Rationale: A patient's ability to remain safe is heavily dependent on their internal state.
, 2
Cognitive awareness allows them to understand instructions and recognize danger, while
sensory awareness (vision, hearing, touch) allows them to perceive environmental hazards.
Deficits in these areas significantly increase the risk of accidents.
Question 4
A nurse is assessing a client for fall risk. Which of the following findings should the nurse
identify as an increased risk for falls?
A) Blood pressure of 120/80 mmHg
B) Urinary frequency or urgency
C) Regular heart rhythm
D) Alert and oriented x4
E) Clear visual acuity
Correct Answer: B) Urinary frequency or urgency
Rationale: Urinary frequency or urgency is a major contributor to falls, particularly in
older adults. The physical rush to reach the bathroom, often in the dark or while fatigued,
increases the likelihood of tripping or slipping. This is especially dangerous if the client also
has gait or balance issues.
Question 5
Which of the following medical conditions is specifically noted for causing gait and balance
problems that increase a patient's fall risk?
A) Hypertension
B) Parkinson’s disease
C) Seasonal allergies
D) Eczema
E) Hypthyroidism
Correct Answer: B) Parkinson’s disease
Rationale: Neurological conditions such as Parkinson’s disease, Multiple Sclerosis (MS), and
Cerebral Palsy directly affect motor control, coordination, and balance. Clients with
Parkinson’s often exhibit a shuffling gait and postural instability, making them highly
susceptible to falls.
Question 6
A nurse is implementing seizure precautions for a high-risk client. Which of the following items
must be available at the bedside?
A) Tongue depressors and a flashlight
B) Soft restraints and a gait belt
C) Oxygen, suction equipment, and an oral airway
D) A heavy blanket and a pillow for the head
E) A cup of water and a straw
Correct Answer: C) Oxygen, suction equipment, and an oral airway
, 3
Rationale: Airway management and oxygenation are the priorities during and after a
seizure. Suction is required to clear secretions or vomit to prevent aspiration, and oxygen is
needed to address hypoxia. Note: While an oral airway should be at the bedside, it should
NOT be forced into the mouth during an active seizure.
Question 7
During a client’s active seizure, which of the following actions should the nurse take?
A) Restrain the client’s limbs to prevent movement
B) Place a padded tongue blade between the teeth
C) Position the client on their side with the head flexed slightly forward
D) Hold the client upright in a chair
E) Administer oral fluids immediately
Correct Answer: C) Position the client on their side with the head flexed slightly forward
Rationale: The goal during a seizure is safety and airway patency. Turning the client to their
side allows saliva or vomit to drain out of the mouth rather than into the lungs. Flexing the
head slightly forward helps keep the airway open. Restraints and putting objects in the
mouth are strictly contraindicated as they cause injury.
Question 8
A nurse is educating a client with orthostatic hypotension on how to prevent falls. Which
instruction is the most appropriate?
A) "Jump out of bed as soon as you wake up to stimulate blood flow."
B) "Avoid drinking water before standing up."
C) "Sit on the side of the bed for a few seconds before standing."
D) "Stand up quickly and then walk immediately to the bathroom."
E) "Keep your head down while you are walking."
Correct Answer: C) Sit on the side of the bed for a few seconds before standing.
Rationale: Orthostatic hypotension is a drop in blood pressure that occurs when changing
positions. To prevent dizziness and syncope, the client should move in stages: dangle the
feet at the bedside, stand while holding onto the bed for a moment, and then begin walking
once they feel stable.
Question 9
When should a nurse utilize physical restraints on a patient?
A) As a first-line intervention for a loud patient
B) When the family requests them for convenience
C) Only when all other less restrictive measures have failed
D) To prevent a patient from leaving against medical advice (AMA)
E) Whenever the nurse is too busy to monitor the patient
Correct Answer: C) Only when all other less restrictive measures have failed
Rationale: Restraints are a last resort due to their impact on client dignity and the risk of
, 4
physical complications. Nurses must first attempt alternatives such as reorientation,
diversional activities, sitters, or electronic monitoring devices before considering restraints.
Question 10
A provider has prescribed restraints for a client. For how long is this prescription valid for an
adult before it must be renewed?
A) 1 hour
B) 2 hours
C) 4 hours
D) 8 hours
E) 24 hours
Correct Answer: C) 4 hours
Rationale: For an adult (18+), a restraint prescription is valid for a maximum of 4 hours.
The provider must see the patient face-to-face to renew the order. The total duration of
consecutive hours for such orders cannot exceed 24 hours without a complete reassessment.
Question 11
In an emergency situation where a patient poses an immediate risk to themselves or others, what
is the nurse's first action regarding restraints?
A) Wait for the provider to arrive and sign the order
B) Call the ethics committee for a consultation
C) Apply the restraints and then obtain a prescription immediately (usually within 1 hour)
D) Ask the patient to sign a consent form before applying restraints
E) Sedate the patient with an unauthorized medication
Correct Answer: C) Apply the restraints and then obtain a prescription immediately (usually
within 1 hour)
Rationale: Client and staff safety is the absolute priority in a crisis. If there is imminent
danger, the nurse may apply restraints. However, legal standards require the nurse to
notify the provider and secure a formal prescription shortly thereafter.
Question 12
Which of the following is a specific nursing responsibility for a client currently in physical
restraints?
A) Assess skin integrity and provide care every 4 hours
B) Tie the restraints to the side rails of the bed
C) Use a double square knot to ensure they stay tight
D) Check that two fingers can fit between the restraint and the patient
E) Leave the patient alone so they can calm down
Correct Answer: D) Check that two fingers can fit between the restraint and the patient
Rationale: To prevent impairment of circulation and nerve damage, restraints must not be
too tight. The "two-finger" rule ensures the device is secure enough to be effective but loose
ANSWERS (ALREADY GRADED A+) | LATEST VERSION 2026 | PROFESSOR VERIFIED
Question 1
When using a Snellen eye chart to assess a client's distance vision, at what distance should the
nurse instruct the client to stand from the chart?
A) 10 feet
B) 14 inches
C) 15 feet
D) 20 feet
E) 30 feet
Correct Answer: D) 20 feet
Rationale: The Snellen eye chart is the standard tool for measuring distance visual acuity.
The standard testing distance is 20 feet (6 meters). The results are recorded as a fraction,
where the numerator is the distance the client stands from the chart (20), and the
denominator is the distance at which a person with normal vision can read that specific
line.
Question 2
A nurse is preparing to assess a client's near vision. Which tool should the nurse use, and at what
distance should it be held?
A) Snellen chart at 20 feet
B) Rosenbaum chart at 14 inches
C) Snellen chart at 14 inches
D) Rosenbaum chart at 20 feet
E) Ishihara plates at 30 inches
Correct Answer: B) Rosenbaum chart at 14 inches
Rationale: The Rosenbaum eye chart (or a Jaeger card) is used to evaluate near vision and
screen for presbyopia. It should be held approximately 14 inches (35 cm) from the client's
eyes. Testing each eye individually and then both together provides an accurate assessment
of the client's functional near vision.
Question 3
Which of the following factors is considered an internal risk factor that affects a patient's ability
to protect themselves from injury?
A) Use of a generic brand of soap
B) Cognitive and sensory awareness
C) The brand of the hospital bed
D) The temperature of the hallway
E) The presence of a roommate
Correct Answer: B) Cognitive and sensory awareness
Rationale: A patient's ability to remain safe is heavily dependent on their internal state.
, 2
Cognitive awareness allows them to understand instructions and recognize danger, while
sensory awareness (vision, hearing, touch) allows them to perceive environmental hazards.
Deficits in these areas significantly increase the risk of accidents.
Question 4
A nurse is assessing a client for fall risk. Which of the following findings should the nurse
identify as an increased risk for falls?
A) Blood pressure of 120/80 mmHg
B) Urinary frequency or urgency
C) Regular heart rhythm
D) Alert and oriented x4
E) Clear visual acuity
Correct Answer: B) Urinary frequency or urgency
Rationale: Urinary frequency or urgency is a major contributor to falls, particularly in
older adults. The physical rush to reach the bathroom, often in the dark or while fatigued,
increases the likelihood of tripping or slipping. This is especially dangerous if the client also
has gait or balance issues.
Question 5
Which of the following medical conditions is specifically noted for causing gait and balance
problems that increase a patient's fall risk?
A) Hypertension
B) Parkinson’s disease
C) Seasonal allergies
D) Eczema
E) Hypthyroidism
Correct Answer: B) Parkinson’s disease
Rationale: Neurological conditions such as Parkinson’s disease, Multiple Sclerosis (MS), and
Cerebral Palsy directly affect motor control, coordination, and balance. Clients with
Parkinson’s often exhibit a shuffling gait and postural instability, making them highly
susceptible to falls.
Question 6
A nurse is implementing seizure precautions for a high-risk client. Which of the following items
must be available at the bedside?
A) Tongue depressors and a flashlight
B) Soft restraints and a gait belt
C) Oxygen, suction equipment, and an oral airway
D) A heavy blanket and a pillow for the head
E) A cup of water and a straw
Correct Answer: C) Oxygen, suction equipment, and an oral airway
, 3
Rationale: Airway management and oxygenation are the priorities during and after a
seizure. Suction is required to clear secretions or vomit to prevent aspiration, and oxygen is
needed to address hypoxia. Note: While an oral airway should be at the bedside, it should
NOT be forced into the mouth during an active seizure.
Question 7
During a client’s active seizure, which of the following actions should the nurse take?
A) Restrain the client’s limbs to prevent movement
B) Place a padded tongue blade between the teeth
C) Position the client on their side with the head flexed slightly forward
D) Hold the client upright in a chair
E) Administer oral fluids immediately
Correct Answer: C) Position the client on their side with the head flexed slightly forward
Rationale: The goal during a seizure is safety and airway patency. Turning the client to their
side allows saliva or vomit to drain out of the mouth rather than into the lungs. Flexing the
head slightly forward helps keep the airway open. Restraints and putting objects in the
mouth are strictly contraindicated as they cause injury.
Question 8
A nurse is educating a client with orthostatic hypotension on how to prevent falls. Which
instruction is the most appropriate?
A) "Jump out of bed as soon as you wake up to stimulate blood flow."
B) "Avoid drinking water before standing up."
C) "Sit on the side of the bed for a few seconds before standing."
D) "Stand up quickly and then walk immediately to the bathroom."
E) "Keep your head down while you are walking."
Correct Answer: C) Sit on the side of the bed for a few seconds before standing.
Rationale: Orthostatic hypotension is a drop in blood pressure that occurs when changing
positions. To prevent dizziness and syncope, the client should move in stages: dangle the
feet at the bedside, stand while holding onto the bed for a moment, and then begin walking
once they feel stable.
Question 9
When should a nurse utilize physical restraints on a patient?
A) As a first-line intervention for a loud patient
B) When the family requests them for convenience
C) Only when all other less restrictive measures have failed
D) To prevent a patient from leaving against medical advice (AMA)
E) Whenever the nurse is too busy to monitor the patient
Correct Answer: C) Only when all other less restrictive measures have failed
Rationale: Restraints are a last resort due to their impact on client dignity and the risk of
, 4
physical complications. Nurses must first attempt alternatives such as reorientation,
diversional activities, sitters, or electronic monitoring devices before considering restraints.
Question 10
A provider has prescribed restraints for a client. For how long is this prescription valid for an
adult before it must be renewed?
A) 1 hour
B) 2 hours
C) 4 hours
D) 8 hours
E) 24 hours
Correct Answer: C) 4 hours
Rationale: For an adult (18+), a restraint prescription is valid for a maximum of 4 hours.
The provider must see the patient face-to-face to renew the order. The total duration of
consecutive hours for such orders cannot exceed 24 hours without a complete reassessment.
Question 11
In an emergency situation where a patient poses an immediate risk to themselves or others, what
is the nurse's first action regarding restraints?
A) Wait for the provider to arrive and sign the order
B) Call the ethics committee for a consultation
C) Apply the restraints and then obtain a prescription immediately (usually within 1 hour)
D) Ask the patient to sign a consent form before applying restraints
E) Sedate the patient with an unauthorized medication
Correct Answer: C) Apply the restraints and then obtain a prescription immediately (usually
within 1 hour)
Rationale: Client and staff safety is the absolute priority in a crisis. If there is imminent
danger, the nurse may apply restraints. However, legal standards require the nurse to
notify the provider and secure a formal prescription shortly thereafter.
Question 12
Which of the following is a specific nursing responsibility for a client currently in physical
restraints?
A) Assess skin integrity and provide care every 4 hours
B) Tie the restraints to the side rails of the bed
C) Use a double square knot to ensure they stay tight
D) Check that two fingers can fit between the restraint and the patient
E) Leave the patient alone so they can calm down
Correct Answer: D) Check that two fingers can fit between the restraint and the patient
Rationale: To prevent impairment of circulation and nerve damage, restraints must not be
too tight. The "two-finger" rule ensures the device is secure enough to be effective but loose
