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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsening with deep breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.
2. A client just received their 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
- C. Provide standby assistance when the client gets out of bed
- D. Encourage foods high in potassium
Correct answer: C
Rationale: The correct answer is to provide standby assistance when the client gets out of bed. Lisinopril can cause hypotension, especially after the first dose, which can lead to dizziness and falls. Standby assistance helps prevent potential injury. Placing the client on cardiac monitoring (choice A) or monitoring oxygen saturation (choice B) are not typically necessary after the first dose of lisinopril unless specific symptoms are present. Encouraging foods high in potassium (choice D) is not directly related to the immediate concern of postural hypotension associated with lisinopril.
3. What is the first action when a client who is admitted with schizophrenia reports hearing voices telling them to harm themselves?
- A. Administer antipsychotic medication
- B. Ask the client what the voices are saying
- C. Distract the client with another activity
- D. Call the healthcare provider
Correct answer: B
Rationale: The correct first action when a client with schizophrenia reports hearing voices telling them to harm themselves is to ask the client what the voices are saying. This is important to assess the content of the hallucinations and determine if there is any immediate danger or suicidal intent. Administering antipsychotic medication without knowing the content of the voices or the level of danger could be inappropriate and potentially harmful. Distracting the client with another activity may not address the underlying issue of the hallucinations commanding harm. Calling the healthcare provider can be done after assessing the situation and gathering information from the client.
4. A nurse is caring for a client who had a stroke and is showing signs of dysphagia. Which of the following findings should the nurse recognize as an indication of this condition?
- A. Abnormal movements of the mouth
- B. Inability to stand without assistance
- C. Paralysis of the right arm
- D. Loss of appetite
Correct answer: A
Rationale: Abnormal movements of the mouth are a common indication of dysphagia, a condition that impairs swallowing function. In clients who have had a stroke, dysphagia can increase the risk of aspiration, leading to serious complications. Inability to stand without assistance (Choice B) is more indicative of motor deficits following a stroke rather than dysphagia. Paralysis of the right arm (Choice C) is a manifestation of hemiplegia, which is common in stroke but not directly related to dysphagia. Loss of appetite (Choice D) may occur in individuals with dysphagia but is not a direct indicator of the condition itself.
5. A nurse is assessing a client with osteoporosis who is experiencing severe pain. The client's respiratory rate is 14/min. Which of the following medications should the nurse administer first?
- A. Promethazine
- B. Hydromorphone
- C. Ketorolac
- D. Amitriptyline
Correct answer: B
Rationale: The correct answer is B, Hydromorphone. Hydromorphone is an opioid analgesic commonly used to manage severe pain effectively. In this case, the client's stable respiratory rate of 14/min indicates that it is safe to administer an opioid for pain relief. Promethazine (choice A) is an antiemetic and antihistamine, not the first choice for severe pain management. Ketorolac (choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may not be potent enough for severe pain relief associated with osteoporosis. Amitriptyline (choice D) is a tricyclic antidepressant, not typically used as a first-line medication for severe pain.
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