PN ATI Capstone Proctored Comprehensive Assessment A

PN ATI Capstone Proctored Comprehensive Assessment A Related

Review PN ATI Capstone Proctored Comprehensive Assessment A related questions and content

A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?

  • A. Alzheimer's disease
  • B. Schizophrenia
  • C. Substance intoxication
  • D. Depression
Correct Answer: B

Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.

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A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

  • A. Limit the client's fluid intake to 1500 mL per day
  • B. Massage the affected extremity to relieve pain
  • C. Apply cold packs to the affected extremity
  • D. Elevate the client's affected extremity when in bed
Correct Answer: D

Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.

A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?

  • A. Position the client with the affected extremity higher than the heart
  • B. Administer acetaminophen for pain
  • C. Massage the affected extremity every 4 hours
  • D. Withhold heparin IV infusion
Correct Answer: D

Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.

A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?

  • A. Glomerular filtration rate of 14 mL/min
  • B. BUN 16 mg/dL
  • C. Serum magnesium 1.8 mg/dL
  • D. Serum phosphorus 4.0 mg/dL
Correct Answer: A

Rationale: A glomerular filtration rate (GFR) of 14 mL/min indicates severely impaired kidney function, often necessitating hemodialysis to support renal function and manage fluid and electrolyte balance. A BUN level of 16 mg/dL falls within the normal range (7-20 mg/dL) and does not specifically indicate the need for hemodialysis. Serum magnesium at 1.8 mg/dL and serum phosphorus at 4.0 mg/dL are also within normal ranges and do not typically prompt the immediate need for hemodialysis in chronic kidney disease.

A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?

  • A. Place the client on cardiac monitoring
  • B. Monitor the client's oxygen saturation level
  • C. Provide standby assistance when getting out of bed
  • D. Encourage foods high in potassium
Correct Answer: C

Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.

A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

  • A. Blood glucose of 150 mg/dL
  • B. Urine output of 20 mL per hour
  • C. Systolic blood pressure of 140 mm Hg
  • D. BUN 20 mg/dL
Correct Answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

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