ATI LEADERSHIP MANAGEMENT PROCTORED EXAMN

ATI LEADERSHIP MANAGEMENT PROCTORED EXAM
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1. The nurse is preparing to lift a patient. Which action will the nurse take
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first?
a. Position a drawsheet under the patient.
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b. Assess weight and determine assistance needs.
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c. Delegate the task to a nursing assistive personnel.
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d. Attempt to manually lift the patient alone before asking for assistance.
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ANS: B N


When lifting, assess the weight you will lift, and determine the assistance you
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will need. The nurse has to assess before positioning a drawsheet or delegatin
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g the task. Manual lifting is the last resort, and it is used when the task at han
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d does not involve lifting most or all of the patient’s weight; most facilities h
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ave a no-lift policy.
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2. The nurse is caring for an older-
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adult patient who has been diagnosedwith a stroke. Which intervention
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will the nurse add to the care plan?
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Encourage the patient to perform as many self-care activities as
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a. possible.
b. Provide a complete bed bath to promote patient comfort.
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c. Coordinate with occupational therapy for gait training.
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d. Place the patient on bed rest to prevent fatigue.
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ANS: A N


Nurses should encourage the older-adult patient to perform as many self-
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careactivities as possible, thereby maintaining the highest level of mobility.
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Sometimes nurses inadvertently contribute to a patient’s immobility by
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providing unnecessary help with activities such as bathing and transferring.
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Placing the patient on bed rest without sufficient ambulation leads to loss of
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mobility and functional decline, resulting in weakness, fatigue, and increased 133
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risk for falls. After a stroke or brain attack, a patient likely receives gait
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, training from a physical therapist; speech rehabilitation from a speech therapi
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st; and help from an occupational therapist for ADLs such as dressing,bathin
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g and toileting, or household chores.
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3. The nurse is observing the way a patient walks. Which aspect is the nurs
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eassessing? N



a. Activity tolerance N




b. Body alignment N



c. Range of motion N N



d. Gait


ANS: D N


Gait describes a particular manner or style of walking. Activity tolerance isth
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e type and amount of exercise or work that a person is able to perform.
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Body alignment refers to the position of the joints, tendons, ligaments, and
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muscles while standing, sitting, and lying. Range of motion is the maximu
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mamount of movement available at a joint in one of the three planes of the
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body: sagittal, frontal, or transverse.
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4. A nurse is assessing the body alignment of a standing patient. Whic
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hfinding will the nurse report as normal?
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When observed laterally, the spinal curves align in a reversed “S”
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a. pattern.
When observed posteriorly, the hips and shoulders form an “S”
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b. pattern.
c. The arms should be crossed over the chest or in the lap.
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d. The feet should be close together with toes pointed out.
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ANS: A N



When the patient is observed laterally, the head is erect and the spinal curves
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are aligned in a reversed “S” pattern. When observed posteriorly, the shoulde
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rs and hips are straight and parallel. The arms hang comfortably at thesides. T
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he feet are slightly apart to achieve a base of support, and the toes are
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pointed forward.
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5. The nurse is evaluating the body alignment of a patient in the sitting
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, position. Which observation by the nurse will indicate a normal finding?
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a. The edge of the seat is in contact with the popliteal space.
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b. Both feet are supported on the floor with ankles flexed.
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c. The body weight is directly on the buttocks only.
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d. The arms hang comfortably at the sides.
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ANS: B N


Both feet are supported on the floor, and the ankles are comfortably flexed. B
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ody weight is evenly distributed on the buttocks and thighs. A 1- to 2-
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inch space is maintained between the edge of the seat and the popliteal space
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on the posterior surface of the knee to ensure that no pressure is placed on th
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e popliteal artery or nerve. The patient’s forearms are supported on the armre
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st,in the lap, or on a table in front of the chair.
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6. The nurse is assessing body alignment for a patient who is immobilized.
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Which patient position will the nurse use?
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a. Supine position N




b. Lateral position N



c. Lateral position with positioning supports
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d. Supine position with no pillow under the patient’s head
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ANS: B N


Assess body alignment for a patient who is immobilized or bedridden with th
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epatient in the lateral position, not supine. Remove all positioning supports fr
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om the bed except for the pillow under the head, and support the body with a
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n adequate mattress.
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7. The nurse is assessing the patient for respiratory complications of
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immobility. Which action will the nurse take when assessing the respiratorys
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ystem?
NN a. Inspect chest wall movements primarily during the expiratory cycle.
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133
b. Auscultate the entire lung region to assess lung sounds.
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