LPN LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?
- A. Sudden weight loss
- B. Regular contractions
- C. Shortness of breath
- D. Vaginal spotting
Correct answer: B
Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.
2. A nurse is admitted to a psychiatric unit and fails to follow her medication regimen. What does this behavior indicate?
- A. Early cognitive impairment
- B. Lack of motivation
- C. Lack of health literacy
- D. Worsening health state
Correct answer: C
Rationale: The correct answer is C, 'Lack of health literacy.' The nurse's inability to follow the medication regimen suggests she may lack health literacy, meaning she may not fully understand how to manage her own health care. Choice A, 'Early cognitive impairment,' is not supported by the information provided in the question as there is no mention of cognitive decline. Choice B, 'Lack of motivation,' is less likely as the behavior is more indicative of a knowledge deficit rather than a lack of drive. Choice D, 'Worsening health state,' is also less likely as the behavior described does not directly imply a worsening health condition but rather a misunderstanding or lack of knowledge on managing health.
3. 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.
4. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?
- A. Massage the affected extremity
- B. Elevate the affected leg
- C. Apply cold packs to the affected leg
- D. Keep the leg dependent to increase circulation
Correct answer: B
Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.
5. A nurse is caring for a client with a new prescription for enoxaparin to prevent DVT. Which of the following is an appropriate action by the nurse?
- A. Expel any air bubbles from the prefilled syringe
- B. Inject the medication in the lateral abdominal wall
- C. Massage the injection site to evenly distribute the medication
- D. Administer NSAIDs for injection site discomfort
Correct answer: B
Rationale: The correct answer is to inject enoxaparin in the lateral abdominal wall. This site is typically recommended for subcutaneous injections of this medication. Expelling air bubbles from prefilled syringes is not necessary and may result in medication loss. Massaging the injection site is contraindicated as it can cause bruising or hematoma formation. Administering NSAIDs for injection site discomfort is unnecessary and not a standard practice.
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