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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?
- A. Have your membranes ruptured?
- B. How far apart are your contractions?
- C. Do you have any active lesions?
- D. Are you positive for beta strep?
Correct answer: C
Rationale: The most appropriate question for the nurse to ask is whether the client has any active herpes lesions. This is crucial because the presence of active lesions can necessitate a cesarean section to prevent transmission of the virus to the newborn. Asking about membrane rupture (choice A) is important but not directly related to the client's herpes simplex virus 2 status. Inquiring about the frequency of contractions (choice B) is relevant for assessing labor progression but does not address the immediate concern of herpes transmission. Asking about being positive for beta strep (choice D) is important for determining the need for prophylactic antibiotics during labor, but it is not directly related to the client's herpes simplex virus 2 status.
2. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?
- A. Increase calcium intake
- B. Provide a diet high in potassium
- C. Restrict protein intake
- D. Increase fluid intake
Correct answer: C
Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.
3. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.
4. A client had a pituitary tumor removed. Which of the following findings requires further assessment?
- A. Glasgow scale score of 15
- B. Blood drainage on dressing measuring 3 cm
- C. Report of dry mouth
- D. Urinary output greater than fluid intake
Correct answer: D
Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.
5. A nurse is assessing a client who had a stroke and is showing signs of dysphagia. Which finding indicates this condition?
- A. Abnormal mouth movements
- B. Inability to stand without assistance
- C. Paralysis of the right arm
- D. Loss of appetite
Correct answer: A
Rationale: Abnormal mouth movements are a key sign of dysphagia, a condition commonly seen in stroke clients. Dysphagia refers to difficulty swallowing, which can manifest as abnormal movements of the mouth during eating or drinking. In stroke patients, dysphagia increases the risk of aspiration, where food or liquids enter the airway instead of the esophagus, leading to potential complications such as pneumonia. Choices B, C, and D are not directly indicative of dysphagia. Inability to stand without assistance may indicate motor deficits, paralysis of the right arm suggests a neurological impairment, and loss of appetite can be a non-specific symptom in many conditions but does not specifically point to dysphagia.
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