ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?
- A. Nausea and vomiting
- B. Increased urination
- C. Tremors
- D. Blurred vision
Correct answer: C
Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.
2. A healthcare provider is caring for a client who has acute renal failure. Which of the following laboratory results should the healthcare provider expect?
- A. Decreased blood urea nitrogen (BUN)
- B. Decreased creatinine
- C. Increased potassium
- D. Increased calcium
Correct answer: C
Rationale: In acute renal failure, the kidneys are unable to excrete potassium efficiently, which can lead to hyperkalemia. As a result, an increased potassium level is a common finding in clients with acute renal failure. Hyperkalemia can have serious cardiac effects, making it essential for healthcare providers to monitor and manage potassium levels closely in clients with renal impairment. Choices A, B, and D are incorrect because in acute renal failure, blood urea nitrogen (BUN) and creatinine levels typically rise due to decreased renal function. Calcium levels are more likely to be decreased in acute renal failure due to impaired activation of vitamin D and subsequent decreased calcium absorption.
3. Which patient statement suggests the presence of dissociative amnesia?
- A. I keep forgetting where I put my keys.
- B. I don’t remember the accident that brought me here or the past two days.
- C. Sometimes I feel like I’m watching myself from outside my body.
- D. I often lose track of time when I’m reading.
Correct answer: B
Rationale: The correct answer is B because the statement reflects a significant gap in memory related to a traumatic event, which is characteristic of dissociative amnesia. Choice A is more indicative of normal forgetfulness and absentmindedness. Choice C suggests depersonalization or dissociative identity disorder rather than dissociative amnesia. Choice D describes a common experience related to concentration while reading, not memory loss as seen in dissociative amnesia.
4. A nurse cares for an Asian American client with a fractured femur. During shift report, which statement by the nurse will another nurse challenge?
- A. The client has requested to wait to receive pain medication.
- B. The client does not want family to visit the room.
- C. The client is a recent immigrant to this country.
- D. The client is stoic and will not complain at all.
Correct answer: D
Rationale: The correct answer is D. Stereotyping the client as stoic and unlikely to complain about pain is incorrect and can lead to inadequate pain management. It is essential for the nurse to assess and address the client's pain regardless of cultural background. Choices A, B, and C are not as critical as they respect the client's autonomy, cultural preferences regarding family visits, and provide relevant background information about the client's immigrant status.
5. A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
- A. Assess deep tendon reflexes every hour.
- B. Obtain a daily weight.
- C. Continuous fetal monitoring
- D. Ambulate twice daily
Correct answer: D
Rationale: The correct answer is D. Ambulating twice daily is not recommended for a client with severe preeclampsia. Clients with severe preeclampsia are at risk for seizures and should be on bed rest to prevent complications. Ambulation can increase blood pressure and the risk of seizure activity in these clients. Assessing deep tendon reflexes, obtaining a daily weight, and continuous fetal monitoring are all appropriate and important interventions for a client with severe preeclampsia to monitor for signs of worsening condition and fetal well-being.
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