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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. 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.
3. A nurse reviewing a patient’s care plan notes a goal of 'Patient will ambulate 50 feet three times in the hallway today.' Which domain of Bloom’s taxonomy is this goal in?
- A. Affective domain
- B. Physical domain
- C. Psychomotor domain
- D. Cognitive domain
Correct answer: C
Rationale: The psychomotor domain involves physical activity and motor skills, such as ambulation, making it the correct domain for this goal. Choices A, B, and D are incorrect: Affective domain focuses on emotions and attitudes, physical domain is not a recognized domain in Bloom's taxonomy, and cognitive domain pertains to knowledge and intellectual skills, none of which directly relate to the physical act of ambulation.
4. A client with a history of urinary tract infections (UTIs) is being cared for by a nurse. Which of the following instructions should the nurse provide to prevent future infections?
- A. Wipe from front to back after urination
- B. Drink 2-3 liters of water per day
- C. Avoid holding urine for long periods
- D. Wear loose-fitting underwear
Correct answer: B
Rationale: The correct answer is to advise the client to drink 2-3 liters of water per day. Adequate hydration helps flush bacteria from the urinary tract, reducing the risk of UTIs. Choice A is incorrect because wiping from front to back is the appropriate technique to prevent the spread of bacteria from the rectal area to the urethra. Choice C is incorrect as holding urine for long periods can contribute to UTIs by allowing bacteria to grow in the bladder. Choice D is incorrect as wearing loose-fitting underwear is recommended to allow air circulation and prevent moisture buildup, reducing the risk of UTIs.
5. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?
- A. Decreased deep tendon reflexes
- B. Elevated blood pressure
- C. Increased urinary output
- D. Hyperreflexia
Correct answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.
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