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ATI LEADERSHIP MANAGEMENT PROCTORED EXAMN
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ATI LEADERSHIP MANAGEMENT PROCTORED EXAMN N N N
1. The nurse is preparing to lift a patient. Which action will the nurse take
N N N N N N N N N N N N N
first?
a. Position a drawsheet under the patient.
N N N N N
b. Assess weight and determine assistance needs.
N N N N N
c. Delegate the task to a nursing assistive personnel.
N N N N N N N
d. Attempt to manually lift the patient alone before asking for assistance.
N N N N N N N N N N
ANS: B N
When lifting, assess the weight you will lift, and determine the assistance you
N N N N N N N N N N N N N
will need. The nurse has to assess before positioning a drawsheet or delegatin
N N N N N N N N N N N N
g the task. Manual lifting is the last resort, and it is used when the task at han
N N N N N N N N N N N N N N N N N
d does not involve lifting most or all of the patient’s weight; most facilities h
N N N N N N N N N N N N N N
ave a no-lift policy.
N N N
2. The nurse is caring for an older-
N N N N N N
adult patient who has been diagnosedwith a stroke. Which intervention
N N N N N N N N N N N
will the nurse add to the care plan?
N N N N N N N
Encourage the patient to perform as many self-care activities as
N N N N N N N N N
a. possible.
b. Provide a complete bed bath to promote patient comfort.
N N N N N N N N
c. Coordinate with occupational therapy for gait training.
N N N N N N
d. Place the patient on bed rest to prevent fatigue.
N N N N N N N N
ANS: A N
Nurses should encourage the older-adult patient to perform as many self-
N N N N N N N N N N
careactivities as possible, thereby maintaining the highest level of mobility.
N N N N N N N N N N
Sometimes nurses inadvertently contribute to a patient’s immobility by
N N N N N N N N
providing unnecessary help with activities such as bathing and transferring.
NN N N N N N N N N N N
Placing the patient on bed rest without sufficient ambulation leads to loss of
N N N N N N N N N N N N N
mobility and functional decline, resulting in weakness, fatigue, and increased 133
N N N N N N N N N N
risk for falls. After a stroke or brain attack, a patient likely receives gait
N N N N N N N N N N N N N
, training from a physical therapist; speech rehabilitation from a speech therapi
N N N N N N N N N N
st; and help from an occupational therapist for ADLs such as dressing,bathin
N N N N N N N N N N N N
g and toileting, or household chores.
N N N N N
3. The nurse is observing the way a patient walks. Which aspect is the nurs
N N N N N N N N N N N N N
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
N N N N N N N N N N N N
e type and amount of exercise or work that a person is able to perform.
N N N N N N N N N N N N N N
Body alignment refers to the position of the joints, tendons, ligaments, and
N N N N N N N N N N N N
muscles while standing, sitting, and lying. Range of motion is the maximu
N N N N N N N N N N N
mamount of movement available at a joint in one of the three planes of the
N N N N N N N N N N N N N N N N
body: sagittal, frontal, or transverse.
N N N N
4. A nurse is assessing the body alignment of a standing patient. Whic
N N N N N N N N N N N
hfinding will the nurse report as normal?
N N N N N N N
When observed laterally, the spinal curves align in a reversed “S”
N N N N N N N N N N
a. pattern.
When observed posteriorly, the hips and shoulders form an “S”
N N N N N N N N N
b. pattern.
c. The arms should be crossed over the chest or in the lap.
N N N N N N N N N N N
d. The feet should be close together with toes pointed out.
N N N N N N N N N
ANS: A N
When the patient is observed laterally, the head is erect and the spinal curves
N N N N N N N N N N N N N N
are aligned in a reversed “S” pattern. When observed posteriorly, the shoulde
N N N N N N N N N N N
rs and hips are straight and parallel. The arms hang comfortably at thesides. T
N N N N N N N N N N N N N N
he feet are slightly apart to achieve a base of support, and the toes are
N N N N N N N N N N N N N N
pointed forward.
NN N
5. The nurse is evaluating the body alignment of a patient in the sitting
N N N N N N N N N N N N 133
, position. Which observation by the nurse will indicate a normal finding?
N N N N N N N N N N
a. The edge of the seat is in contact with the popliteal space.
N N N N N N N N N N N
b. Both feet are supported on the floor with ankles flexed.
N N N N N N N N N
c. The body weight is directly on the buttocks only.
N N N N N N N N
d. The arms hang comfortably at the sides.
N N N N N N
ANS: B N
Both feet are supported on the floor, and the ankles are comfortably flexed. B
N N N N N N N N N N N N N
ody weight is evenly distributed on the buttocks and thighs. A 1- to 2-
N N N N N N N N N N N N N
inch space is maintained between the edge of the seat and the popliteal space
N N N N N N N N N N N N N N
on the posterior surface of the knee to ensure that no pressure is placed on th
N N N N N N N N N N N N N N N
e popliteal artery or nerve. The patient’s forearms are supported on the armre
N N N N N N N N N N N N
st,in the lap, or on a table in front of the chair.
N N N N N N N N N N N N
6. The nurse is assessing body alignment for a patient who is immobilized.
N N N N N N N N N N N
Which patient position will the nurse use?
N N N N N N
a. Supine position N
b. Lateral position N
c. Lateral position with positioning supports
N N N N
d. Supine position with no pillow under the patient’s head
N N N N N N N N
ANS: B N
Assess body alignment for a patient who is immobilized or bedridden with th
N N N N N N N N N N N N
epatient in the lateral position, not supine. Remove all positioning supports fr
N N N N N N N N N N N N
om the bed except for the pillow under the head, and support the body with a
N N N N N N N N N N N N N N N
n adequate mattress.
N N
7. The nurse is assessing the patient for respiratory complications of
N N N N N N N N N
immobility. Which action will the nurse take when assessing the respiratorys
N N N N N N N N N N N
ystem?
NN a. Inspect chest wall movements primarily during the expiratory cycle.
N N N N N N N N N
133
b. Auscultate the entire lung region to assess lung sounds.
N N N N N N N N
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