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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?
- A. Why do you think your life isn’t worth living anymore?
- B. Do you have a plan to end your life?
- C. I need to understand what you mean by misery.
- D. You can trust me to share your thoughts.
Correct answer: B
Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.
2. 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.
3. When designing a program for young adults regarding safe sexual practices, which strategy might reach the greatest number in the target group?
- A. Web-based applications
- B. Print-based media such as newspapers
- C. Television advertisements
- D. Brochures in kiosks in malls
Correct answer: A
Rationale: Web-based applications are the most effective strategy for reaching young adults in the target group regarding safe sexual practices. Young adults today are highly engaged with mobile technology and the internet, making web-based applications the most accessible and convenient method to disseminate information. Print-based media like newspapers may not have the same reach and engagement among young adults. Television advertisements might reach a broader audience, but they may not be as targeted to the specific demographic of young adults. Brochures in kiosks in malls are less likely to reach a large number of young adults compared to web-based applications, which can be accessed anytime and anywhere through mobile devices.
4. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?
- A. A client with cystic fibrosis who has a productive cough and reports thirst
- B. A client with gastroenteritis who is lethargic and confused
- C. A client with diabetes mellitus whose blood glucose is 185 mg/dL
- D. A client with sickle cell anemia who reports pain 15 minutes after receiving analgesics
Correct answer: B
Rationale: Lethargy and confusion in a client with gastroenteritis are concerning findings that may indicate severe dehydration or electrolyte imbalance, requiring immediate intervention. While the other options are important, they do not pose an immediate life-threatening risk compared to the altered mental status in a client with gastroenteritis.
5. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?
- A. I understand methadone slows my breathing.
- B. I understand methadone may cause me to have trouble sleeping.
- C. I will avoid alcohol while I’m taking this medication.
- D. I’ll change positions slowly, especially when standing.
Correct answer: B
Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.
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