ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
2. The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process?
- A. Do you have any children living in your home?
- B. Do you have a spouse?
- C. Do you have a chronic disease?
- D. Do you have any religious beliefs that will influence your care?
Correct answer: C
Rationale: The correct answer is C: 'Do you have a chronic disease?' Patients with chronic diseases are more susceptible to infections due to factors like general debilitation and nutritional impairment. Choices A, B, and D are incorrect because having children in the home, having a spouse, or religious beliefs do not directly impact susceptibility to infectious diseases.
3. A family was referred to crisis intervention services after a natural disaster. One family member refuses to attend, stating, 'No way, I'm not crazy.' What is the nurse's best response?
- A. Don't worry now. The psychiatrists are well trained to help.
- B. Many times, disasters can create mental health problems, so you really should participate with your family.
- C. This will help your family communicate better.
- D. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.
Correct answer: D
Rationale: The nurse should reassure the family member that seeking help does not imply mental illness, but is part of coping with the disaster.
4. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?
- A. Loud volume of the television set
- B. Wall-to-wall carpet in the living room
- C. Low chairs without armrests
- D. Use of indirect lighting
Correct answer: C
Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.
5. A client has a prescription for vancomycin 1g IV intermittent infusion over 30 minutes every 12 hours. What action should the nurse take?
- A. Start the infusion immediately
- B. Slow down the infusion rate
- C. Contact the provider for prescription clarification
- D. Check blood pressure during the infusion
Correct answer: C
Rationale: The correct action for the nurse to take is to contact the provider for prescription clarification. Administering vancomycin over less than 60 minutes can lead to infusion reactions like hypotension and flushing. Starting the infusion immediately (choice A) is incorrect as it goes against the prescribed rate. Slowing down the infusion rate (choice B) without provider approval can result in underdosing the medication. Checking blood pressure during the infusion (choice D) is important but not the most immediate action needed in this situation.
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