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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?
- A. Sunken anterior fontanel
- B. Tenting skin turgor
- C. Flat anterior fontanel
- D. Hyperpnea
Correct answer: C
Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.
2. A client with mild persistent asthma is being taught about montelukast by a nurse. Which statement by the client indicates understanding?
- A. I will use this for asthma attacks.
- B. I should take this before exercise.
- C. This medication will decrease swelling and mucus production.
- D. I can stop this medication after 10 days.
Correct answer: C
Rationale: The correct answer is C: 'This medication will decrease swelling and mucus production.' Montelukast is a leukotriene receptor antagonist that works by reducing swelling and mucus production in the airways, helping to manage asthma symptoms in the long term. Choices A, B, and D are incorrect because montelukast is not used for immediate relief during asthma attacks, pre-exercise prophylaxis, or short-term treatment; instead, it is taken regularly for asthma control.
3. A nurse is planning care for a client with a sealed radiation implant. Which intervention should the nurse implement?
- A. Remove dirty linens after double-bagging them
- B. Wear a dosimeter badge in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family remains 3 feet away from the client
Correct answer: B
Rationale: The nurse should wear a dosimeter badge to monitor radiation exposure when caring for a client with a sealed radiation implant.
4. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?
- A. Hypnosis promotes increased control of pain perception during labor
- B. Hypnosis uses therapeutic touch to reduce anxiety
- C. Hypnosis focuses on biofeedback as a relaxation technique
- D. Hypnosis provides instruction to minimize pain
Correct answer: A
Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.
5. A client with hepatic encephalopathy is being cared for by a nurse. Which food selection indicates the client understands dietary teaching?
- A. A sandwich and milkshake
- B. Rice with black beans
- C. Cottage cheese and tuna lettuce
- D. Three-egg omelet with low-sodium ham
Correct answer: B
Rationale: For clients with hepatic encephalopathy, foods high in protein like cottage cheese and tuna should be avoided. Plant-based protein sources like beans are recommended due to their lower ammonia production during digestion. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they include high-protein or high-sodium foods that can worsen the condition of hepatic encephalopathy.
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