ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A healthcare professional is assessing a client for signs of anaphylaxis. Which of the following findings should the healthcare professional look for?
- A. Bradycardia
- B. Hypotension
- C. Increased appetite
- D. Decreased respiratory rate
Correct answer: B
Rationale: Hypotension is a critical sign of anaphylaxis. During anaphylaxis, there is a widespread vasodilation leading to a drop in blood pressure, which manifests as hypotension. This can be accompanied by other symptoms such as swelling, difficulty breathing, hives, and itching. Bradycardia (choice A) is not typically associated with anaphylaxis; instead, tachycardia is more common due to the body's response to the allergic reaction. Increased appetite (choice C) is unrelated to anaphylaxis, as individuals experiencing anaphylaxis often feel unwell and may have nausea or vomiting. Decreased respiratory rate (choice D) is also not a typical finding in anaphylaxis; instead, respiratory distress and wheezing are more commonly observed.
2. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?
- A. Glaucoma
- B. Hypertension
- C. Polycythemia
- D. Migraine headaches
Correct answer: A
Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.
3. When resolving a conflict, which statement made by the charge nurse is an example of smoothing?
- A. You have been a nurse a long time, so I’m sure you’re capable of the tasks.
- B. If you prefer, I can take over your assignment.
- C. We can switch your assignment with someone else.
- D. Let’s discuss your concerns in a private setting.
Correct answer: A
Rationale: The correct answer is A because it exemplifies smoothing, a conflict resolution strategy where the charge nurse reassures the staff nurse of their capabilities. Choice B offers to take over the assignment, which is more of a compromising strategy. Choice C suggests switching assignments, which aligns with compromising rather than smoothing. Choice D proposes a discussion in a private setting, indicating a collaborating approach rather than smoothing.
4. A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?
- A. Non-Hodgkin's lymphoma
- B. Endometriosis
- C. Breast cancer
- D. Polycystic ovary syndrome
Correct answer: C
Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow. Choice A, Non-Hodgkin's lymphoma, is incorrect because tamoxifen is not indicated for its treatment. Choice B, Endometriosis, is incorrect as tamoxifen is not used for this condition. Choice D, Polycystic ovary syndrome, is also incorrect since tamoxifen is not a treatment for this syndrome.
5. A nurse is assessing a male adolescent client who has heart failure. Based on the client’s chart, which of the following actions should the nurse plan to take?
- A. Withhold spironolactone
- B. Administer ferrous sulfate
- C. Administer furosemide
- D. Withhold digoxin
Correct answer: C
Rationale: The correct answer is to administer furosemide. Furosemide is a diuretic commonly used in heart failure to manage fluid retention, helping alleviate symptoms like edema and shortness of breath. Withholding spironolactone, a potassium-sparing diuretic, could lead to electrolyte imbalances. Administering ferrous sulfate is used to treat iron deficiency anemia, not heart failure. Withholding digoxin, a medication used in heart failure to improve heart function, can worsen the client's condition.
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