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PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is providing discharge instructions to a client following a below-the-knee amputation. Which of the following instructions should the nurse include?
- A. Avoid sitting in a chair for prolonged periods.
- B. Sleep with a pillow under the residual limb.
- C. Elevate the limb continuously for the first 48 hours.
- D. Apply lotion to the residual limb daily.
Correct answer: A
Rationale: The correct answer is to instruct the client to avoid sitting in a chair for prolonged periods. This is important to prevent contractures from developing in the residual limb. Sleeping with a pillow under the residual limb can contribute to contracture formation rather than prevent it. While elevation of the limb is important for reducing swelling and promoting circulation, continuous elevation for 48 hours is not necessary and may not be practical. Applying lotion to the residual limb daily is generally not recommended immediately post-amputation as the wound site needs to heal without interference from lotions or creams.
2. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?
- A. Place weight on the underarms.
- B. Keep the elbows extended when walking.
- C. Support your weight on your hands.
- D. Hold the crutches 10 cm in front of you when standing.
Correct answer: C
Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.
3. A client has a new prescription for metformin. Which of the following instructions should the nurse include in the teaching?
- A. Take the medication at bedtime
- B. Monitor your blood glucose level before each meal
- C. Stop taking the medication if you develop muscle pain
- D. You may experience diarrhea with this medication
Correct answer: D
Rationale: The correct answer is D: 'You may experience diarrhea with this medication.' Diarrhea is a common side effect of metformin, particularly when initiating the medication. It is important for clients to be aware of this potential side effect. Option A is incorrect because metformin is usually taken with meals to reduce gastrointestinal side effects. Option B is not directly related to metformin use. Option C is incorrect as muscle pain is not a common side effect of metformin and does not warrant stopping the medication.
4. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused
- B. Request a prescription for PRN restraints when the client is wandering
- C. Dim the lighting in the client’s room
- D. Leave one side rail up on the client's bed
Correct answer: D
Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.
5. A healthcare professional is assessing a client who is experiencing a thyroid storm. Which of the following is an expected finding?
- A. Hypothermia
- B. Bradycardia
- C. Hypertension
- D. Lethargy
Correct answer: C
Rationale: In a thyroid storm, which is a severe complication of hyperthyroidism, hypertension is an expected finding. Other common manifestations include tachycardia, hyperthermia, and agitation. Hypothermia (choice A) is not expected in a thyroid storm as the body temperature is usually elevated due to increased metabolic rate. Bradycardia (choice B) is not typical in a thyroid storm; instead, tachycardia is more common. Lethargy (choice D) is not a typical finding in a thyroid storm, as clients are usually agitated due to excess thyroid hormone levels.
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