ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. What teaching points are important for the nurse to discuss with a client with hearing loss who has been fitted for a hearing aid?
- A. Use the highest setting to promote full auditory comprehension
- B. Use mild soap and water to clean the ear mold
- C. Turn the hearing aid off to conserve battery life during hours of sleep only
- D. Immerse the hearing aid in saline solution to keep it hygienic
Correct answer: B
Rationale: The correct teaching point for a client with hearing loss who has been fitted for a hearing aid is to use mild soap and water to clean the ear mold. It is important to keep the ear mold clean to prevent infections and maintain proper functioning. Choice A is incorrect because using the highest setting can lead to discomfort and may not be necessary for all situations. Choice C is incorrect as the hearing aid should generally be turned off when not in use, not just during sleep, to conserve battery life. Choice D is incorrect as immersing the hearing aid in saline solution can damage the device; it should be kept dry to prevent malfunction.
2. A client receiving chemotherapy reports nausea and vomiting. What is the nurse's priority intervention?
- A. Administer antiemetic medication before meals
- B. Encourage the client to eat small, frequent meals
- C. Instruct the client to avoid eating during treatment
- D. Provide the client with cold beverages during meals
Correct answer: A
Rationale: The correct answer is A: Administer antiemetic medication before meals. When a client receiving chemotherapy reports nausea and vomiting, administering antiemetic medication before meals is a priority intervention to help reduce nausea associated with chemotherapy. This proactive approach can prevent or minimize the symptoms, improving the client's quality of life during treatment. Choice B is incorrect because while encouraging the client to eat small, frequent meals can be helpful, administering antiemetic medication is the priority to address the immediate symptoms. Choice C is incorrect as avoiding eating during treatment may lead to nutritional deficits, and choice D is incorrect because providing cold beverages during meals may not effectively address the nausea and vomiting symptoms.
3. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.”
- B. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
- C. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not getting better?”
- D. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”
Correct answer: A
Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.
4. When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?
- A. Perform a sharp hand clap near the infant.
- B. Hold the newborn vertically allowing one foot to touch the table surface.
- C. Place a finger at the base of the newborn's toes.
- D. Turn the newborn's head quickly to one side.
Correct answer: A
Rationale: The correct answer is A: Perform a sharp hand clap near the infant. The Moro reflex, also known as the startle reflex, is elicited by a sudden stimuli such as a sharp hand clap near the infant. This reflex is characterized by the infant's arms extending and then flexing with a distinctive 'startle' motion. It is a normal and expected reflex in newborns, typically disappearing by 3-6 months of age. Choices B, C, and D are incorrect because they do not elicit the Moro reflex; holding the newborn vertically (choice B) or placing a finger at the base of the newborn's toes (choice C) are associated with other reflexes, while turning the newborn's head quickly to one side (choice D) is related to the tonic neck reflex.
5. The nurse is caring for a client with a spinal cord injury. Which intervention should the nurse implement to prevent autonomic dysreflexia?
- A. Restrict the client's fluid intake.
- B. Keep the client's room warm.
- C. Ensure the client's bladder is emptied regularly.
- D. Limit the client's intake of high-fiber foods.
Correct answer: C
Rationale: To prevent autonomic dysreflexia in clients with spinal cord injuries, it is crucial to ensure the client's bladder is emptied regularly. Bladder distention is a common trigger for autonomic dysreflexia in these clients. Keeping the bladder empty helps prevent the complications associated with autonomic dysreflexia, such as dangerously high blood pressure. Choices A, B, and D are incorrect. Restricting fluid intake can lead to dehydration, keeping the room warm is not directly related to preventing autonomic dysreflexia, and limiting high-fiber foods is not a primary intervention for this condition.
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