a nurse is assessing a client who has a long arm cast which of the following findings indicates a moderate complication when assessing for acute compa
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment A

1. A healthcare provider is assessing a client who has a long arm cast. Which of the following findings indicates a moderate complication when assessing for acute compartment syndrome?

Correct answer: D

Rationale: Edema is a common sign of acute compartment syndrome, which is a medical emergency caused by increased pressure within a muscle compartment, requiring immediate intervention. Shortness of breath (Choice A) is more indicative of a respiratory issue rather than acute compartment syndrome. Petechiae (Choice B) are pinpoint, round spots that appear on the skin due to bleeding under the skin and are not typically associated with acute compartment syndrome. Change in mental status (Choice C) is more suggestive of neurological issues rather than acute compartment syndrome.

2. A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Decrease in elasticity.' As individuals age, they typically experience a decrease in skin elasticity, leading to sagging skin and increased wrinkles. This change in elasticity can contribute to various skin-related issues such as pressure ulcers and delayed wound healing. Choices A, B, and D are incorrect because older adults do not experience an increase in elasticity or moisture levels, and while there may be changes in pigmentation, the primary change related to aging in the integumentary system is a decrease in elasticity.

3. A nurse is caring for a client who has a prescription for a narcotic medication. After administering, the nurse is left with an unused portion. What should the nurse do?

Correct answer: C

Rationale: The correct answer is to discard the medication with another nurse as a witness. Controlled substances, such as narcotic medications, must be properly disposed of to prevent misuse or diversion. Having another nurse witness the disposal ensures accountability and follows proper protocols. Storing the unused medication for later use (Choice A) is unsafe and could lead to misuse. Discarding the medication in a regular trash bin (Choice B) is inappropriate as it does not ensure proper disposal of a controlled substance. Reporting the unused portion to the provider (Choice D) is not the immediate action needed for proper medication disposal.

4. A nurse is caring for a client who had a stroke and is showing signs of dysphagia. Which of the following findings should the nurse recognize as an indication of this condition?

Correct answer: A

Rationale: Abnormal movements of the mouth are a common indication of dysphagia, a condition that impairs swallowing function. In clients who have had a stroke, dysphagia can increase the risk of aspiration, leading to serious complications. Inability to stand without assistance (Choice B) is more indicative of motor deficits following a stroke rather than dysphagia. Paralysis of the right arm (Choice C) is a manifestation of hemiplegia, which is common in stroke but not directly related to dysphagia. Loss of appetite (Choice D) may occur in individuals with dysphagia but is not a direct indicator of the condition itself.

5. While providing education about the use of lorazepam, which of the following should be included?

Correct answer: A

Rationale: The correct answer is A: 'It can cause dependency.' Lorazepam is a benzodiazepine known to cause dependency, so it is crucial for clients to be informed about this potential risk. Choice B is incorrect as combining lorazepam with alcohol can lead to increased sedation and other adverse effects. Choice C is incorrect because lorazepam, like any medication, can have side effects such as drowsiness, dizziness, or confusion. Choice D is also incorrect as lorazepam is a sedative-hypnotic medication, not a stimulant.

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