ATI LPN
PN ATI Capstone Fundamentals Quiz
1. A healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?
- A. Numeric rating scale
- B. Behavioral indicators
- C. Visual analog scale
- D. Faces pain scale
Correct answer: B
Rationale: For clients with dementia who have difficulty communicating, assessing pain using behavioral indicators like increased agitation and restlessness is more effective than relying on self-reported scales such as numeric rating scale, visual analog scale, or faces pain scale. Behavioral indicators provide valuable insights into pain perception in individuals who may have challenges expressing themselves verbally.
2. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the healthcare provider
- B. Recheck the client's BP
- C. Document the findings
- D. Administer antihypertensive medication
Correct answer: B
Rationale: The correct answer is to recheck the client's BP. It is essential for the nurse to verify the accuracy of the initial reading by reassessing the blood pressure. Notifying the healthcare provider or administering antihypertensive medication should only occur after confirming the elevated blood pressure through a recheck. Documenting the findings is important but should follow the confirmation of the BP reading.
3. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Dark urine
- D. Increased thirst
Correct answer: A
Rationale: Bladder distention is the correct sign of catheter occlusion. When a catheter is occluded, the urine cannot drain properly, leading to the buildup of urine in the bladder and subsequent distention. Frequent urination, dark urine, and increased thirst are not typical signs of catheter occlusion. Frequent urination can be a sign of conditions like urinary tract infection, dark urine may indicate dehydration or other issues, and increased thirst can be related to various factors like diabetes or medication side effects.
4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct answer: C
Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.
5. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct answer: B
Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.
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