a nurse in a mental health facility receives a change of shift report on four clients which of the following clients should the nurse assess first
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

2. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis?

Correct answer: A

Rationale: The correct answer is A: Early menopause. A client who goes into early menopause, from natural or surgical causes, is at greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Choice B, history of falls, is not a direct risk factor for osteoporosis but can lead to fractures in individuals with osteoporosis. Choice C, African American race, is actually associated with a lower risk of osteoporosis compared to Caucasian or Asian descent. Choice D, obesity, is generally considered a protective factor against osteoporosis due to the increased mechanical loading on bones.

3. A client newly diagnosed with asthma is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Keeping a diary of albuterol use helps monitor the frequency and severity of asthma symptoms, which can guide the healthcare provider in adjusting treatment as needed. Option A is incorrect because fluticasone is a controller medication used for long-term management, not for treating acute asthma attacks. Option B is incorrect as using a peak flow meter once a week may not provide real-time information on asthma control. Option D is incorrect as limiting fluid intake does not directly prevent mucus production in asthma.

4. A client has been prescribed nitroglycerin for chest pain. Which of the following should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B. Nitroglycerin tablets should be stored in a cool, dark place to maintain their potency. Storing them correctly ensures that they remain effective when needed. Choices A, C, and D are incorrect. Taking one tablet every hour is not the correct dosing regimen for nitroglycerin. Nitroglycerin is usually taken as needed at the onset of chest pain, with specific instructions from the healthcare provider. Taking nitroglycerin with food or antacids is not necessary, as it is usually placed under the tongue for rapid absorption.

5. A client is receiving ferrous sulfate. Which of the following should be monitored?

Correct answer: B

Rationale: The correct answer is B: Hemoglobin levels. Ferrous sulfate is used to treat iron deficiency anemia by increasing the body's iron stores. Monitoring hemoglobin levels is crucial as it reflects the effectiveness of the treatment in improving the client's anemia. Serum potassium levels (Choice A) are typically not directly affected by ferrous sulfate. Liver function tests (Choice C) and blood glucose levels (Choice D) are not routinely monitored when a client is receiving ferrous sulfate unless there are specific indications or pre-existing conditions that warrant such monitoring.

Similar Questions

A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?
A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses