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. j j j j j
b. Assess weight and determine assistance needs. j j j j j
c. Delegate the task to a nursing assistive personnel. j j j j j j j
d. Attempt to manually lift the patient alone before asking for assistance.
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ANS: B j
When lifting, assess the weight you will lift, and determine the assistance youwill
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need. The nurse has to assess before positioning a drawsheet or delegating the task
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. Manual lifting is the last resort, and it is used when the task at hand does not invol
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ve lifting most or all of the patient’s weight; most facilities have 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 will
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the nurse add to the care plan?
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Encourage the patient to perform as many self-care activities as j j j j j j j j j
a. possible.
b. Provide a complete bed bath to promote patient comfort.
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c. Coordinate with occupational therapy for gait training. j j j j j j
d. Place the patient on bed rest to prevent fatigue.
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ANS:A j
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. Placi
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ng the patient on bed rest without sufficient ambulation leads to loss of mobility a
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nd functional decline, resulting in weakness, fatigue, and increasedrisk for falls.
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133
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 therapist; a
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nd help from an occupational therapist for ADLs such as dressing,bathing and toil
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eting, or household chores. j j j
3. The nurse is observing the way a patient walks. Which aspect is the nurseasse
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ssing?
a. Activity tolerance j
b. Body alignment j
c. Range of motion j j
d. Gait
ANS: D j
Gait describes a particular manner or style of walking. Activity tolerance isthe typ
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e 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 musc
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les while standing, sitting, and lying. Range of motion is the maximumamount o
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f movement available at a joint in one of the three planes of the body: sagittal, fro
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ntal, or transverse. j j
4. A nurse is assessing the body alignment of a standing patient. Whichfind
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ing will the nurse report as normal?
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When observed laterally, the spinal curves align in a reversed “S” j j j j j j j j j j
a. pattern.
When observed posteriorly, the hips and shoulders form an “S” j j j j j j j j j
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 j
When the patient is observed laterally, the head is erect and the spinal curves are al
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igned in a reversed “S” pattern. When observed posteriorly, the shoulders and hip
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s are straight and parallel. The arms hang comfortably at thesides. The feet are slig
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htly 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 j
Both feet are supported on the floor, and the ankles are comfortably flexed. Body
j j j j j j j j j j j j j j
weight is evenly distributed on the buttocks and thighs. A 1- to 2-
j j j j j j j j j j j j
inch space is maintained between the edge of the seat and the popliteal space on th
j j j j j j j j j j j j j j j
e posterior surface of the knee to ensure that no pressure is placed on the popliteal a
j j j j j j j j j j j j j j j j
rtery or nerve. The patient’s forearms are supported on the armrest,in the lap, or on
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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 j
b. Lateral position j
c. Lateral position with positioning supports j j j j
d. Supine position with no pillow under the patient’s head j j j j j j j j
ANS: B j
Assess body alignment for a patient who is immobilized or bedridden with thepati
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ent in the lateral position, not supine. Remove all positioning supports from the be
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d except for the pillow under the head, and support the body with an adequate mattr
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ess.
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 respiratorysyste
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m?
jj 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. j j j j j j j j
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1. The nurse is preparing to lift a patient. Which action will the nurse take
j j j j j j j j j j j j j
first?
a. Position a drawsheet under the patient. j j j j j
b. Assess weight and determine assistance needs. j j j j j
c. Delegate the task to a nursing assistive personnel. j j j j j j j
d. Attempt to manually lift the patient alone before asking for assistance.
j j j j j j j j j j
ANS: B j
When lifting, assess the weight you will lift, and determine the assistance youwill
j j j j j j j j j j j j j j
need. The nurse has to assess before positioning a drawsheet or delegating the task
j j j j j j j j j j j j j
. Manual lifting is the last resort, and it is used when the task at hand does not invol
j j j j j j j j j j j j j j j j j j
ve lifting most or all of the patient’s weight; most facilities have a no-lift policy.
j j j j j j j j j j j j j j
2. The nurse is caring for an older-
j j j j j j
adult patient who has been diagnosedwith a stroke. Which intervention will
j j j j j j j j j j j j
the nurse add to the care plan?
j j j j j j
Encourage the patient to perform as many self-care activities as j j j j j j j j j
a. possible.
b. Provide a complete bed bath to promote patient comfort.
j j j j j j j j
c. Coordinate with occupational therapy for gait training. j j j j j j
d. Place the patient on bed rest to prevent fatigue.
j j j j j j j j
ANS:A j
Nurses should encourage the older-adult patient to perform as many self-
j j j j j j j j j j
careactivities as possible, thereby maintaining the highest level of mobility.
j j j j j j j j j j
Sometimes nurses inadvertently contribute to a patient’s immobility by
j j j j j j j j
providing unnecessary help with activities such as bathing and transferring. Placi
jj j j j j j j j j j j
ng the patient on bed rest without sufficient ambulation leads to loss of mobility a
j j j j j j j j j j j j j j
nd functional decline, resulting in weakness, fatigue, and increasedrisk for falls.
j j j j j j j j j j j j
133
After a stroke or brain attack, a patient likely receives gait
j j j j j j j j j j
, training from a physical therapist; speech rehabilitation from a speech therapist; a
j j j j j j j j j j j
nd help from an occupational therapist for ADLs such as dressing,bathing and toil
j j j j j j j j j j j j j
eting, or household chores. j j j
3. The nurse is observing the way a patient walks. Which aspect is the nurseasse
j j j j j j j j j j j j j j
ssing?
a. Activity tolerance j
b. Body alignment j
c. Range of motion j j
d. Gait
ANS: D j
Gait describes a particular manner or style of walking. Activity tolerance isthe typ
j j j j j j j j j j j j j
e and amount of exercise or work that a person is able to perform.
j j j j j j j j j j j j j
Body alignment refers to the position of the joints, tendons, ligaments, and musc
j j j j j j j j j j j j
les while standing, sitting, and lying. Range of motion is the maximumamount o
j j j j j j j j j j j j j
f movement available at a joint in one of the three planes of the body: sagittal, fro
j j j j j j j j j j j j j j j j
ntal, or transverse. j j
4. A nurse is assessing the body alignment of a standing patient. Whichfind
j j j j j j j j j j j j
ing will the nurse report as normal?
j j j j j j
When observed laterally, the spinal curves align in a reversed “S” j j j j j j j j j j
a. pattern.
When observed posteriorly, the hips and shoulders form an “S” j j j j j j j j j
b. pattern.
c. The arms should be crossed over the chest or in the lap.
j j j j j j j j j j j
d. The feet should be close together with toes pointed out.
j j j j j j j j j
ANS:A j
When the patient is observed laterally, the head is erect and the spinal curves are al
j j j j j j j j j j j j j j j
igned in a reversed “S” pattern. When observed posteriorly, the shoulders and hip
j j j j j j j j j j j j
s are straight and parallel. The arms hang comfortably at thesides. The feet are slig
j j j j j j j j j j j j j j j
htly apart to achieve a base of support, and the toes are
j j j j j j j j j j j
pointed forward.
jj j
5. The nurse is evaluating the body alignment of a patient in the sitting
j j j j j j j j j j j j 133
, position. Which observation by the nurse will indicate a normal finding?
j j j j j j j j j j
a. The edge of the seat is in contact with the popliteal space.
j j j j j j j j j j j
b. Both feet are supported on the floor with ankles flexed.
j j j j j j j j j
c. The body weight is directly on the buttocks only.
j j j j j j j j
d. The arms hang comfortably at the sides.
j j j j j j
ANS: B j
Both feet are supported on the floor, and the ankles are comfortably flexed. Body
j j j j j j j j j j j j j j
weight is evenly distributed on the buttocks and thighs. A 1- to 2-
j j j j j j j j j j j j
inch space is maintained between the edge of the seat and the popliteal space on th
j j j j j j j j j j j j j j j
e posterior surface of the knee to ensure that no pressure is placed on the popliteal a
j j j j j j j j j j j j j j j j
rtery or nerve. The patient’s forearms are supported on the armrest,in the lap, or on
j j j j j j j j j j j j j j j j
a table in front of the chair.
j j j j j j
6. The nurse is assessing body alignment for a patient who is immobilized.
j j j j j j j j j j j
Which patient position will the nurse use?
j j j j j j
a. Supine position j
b. Lateral position j
c. Lateral position with positioning supports j j j j
d. Supine position with no pillow under the patient’s head j j j j j j j j
ANS: B j
Assess body alignment for a patient who is immobilized or bedridden with thepati
j j j j j j j j j j j j j
ent in the lateral position, not supine. Remove all positioning supports from the be
j j j j j j j j j j j j j
d except for the pillow under the head, and support the body with an adequate mattr
j j j j j j j j j j j j j j j
ess.
7. The nurse is assessing the patient for respiratory complications of
j j j j j j j j j
immobility. Which action will the nurse take when assessing the respiratorysyste
j j j j j j j j j j j
m?
jj a. Inspect chest wall movements primarily during the expiratory cycle.
j j j j j j j j j
133
b. Auscultate the entire lung region to assess lung sounds. j j j j j j j j
