ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?
- A. Report any sign of infection to the provider immediately
- B. Expect your blood pressure to increase
- C. Easy bruising may occur while taking this medication
- D. Muscle rigidity is an expected adverse effect during the first few days of therapy
Correct answer: A
Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.
2. A nurse is providing teaching to a parent of a child with celiac disease. Which food choice should the nurse include?
- A. Rice
- B. Barley
- C. Wheat
- D. Rye
Correct answer: A
Rationale: The correct answer is A, Rice. In celiac disease, individuals must avoid gluten-containing foods. Rice is a safe option as it is gluten-free. Barley (choice B), Wheat (choice C), and Rye (choice D) all contain gluten and should be avoided in a celiac diet. Therefore, the nurse should emphasize including rice in the child's diet.
3. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?
- A. Hip pallor
- B. Leg abduction
- C. Muscle spasms
- D. Leg lengthening
Correct answer: C
Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.
4. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
- A. Hold the cane with your left hand
- B. Move the cane forward 18 inches with each step
- C. When walking, move your left foot forward first
- D. Keep your elbow straight when you hold the cane
Correct answer: C
Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.
5. A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the following information should the nurse include in the teaching?
- A. This medication may increase your blood pressure
- B. Breast tenderness may occur with this medication
- C. You can double the dose of medication if you feel anxious
- D. Notify the provider if pregnancy is desired or suspected
Correct answer: D
Rationale: Pregnancy can complicate alcohol withdrawal treatment, and the provider should be notified.
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