ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?
- A. Pruritus
- B. Hypertension
- C. Bradykinesia
- D. Xerostomia
Correct answer: C
Rationale: The correct answer is C: Bradykinesia. Bradykinesia, which refers to slowness of movement, is a characteristic symptom of Parkinson's disease. Other common manifestations in Parkinson's disease include tremors, muscle rigidity, orthostatic hypotension, and drooling. Pruritus (choice A) is unrelated to Parkinson's disease. While hypertension (choice B) can coexist with Parkinson's disease due to autonomic dysfunction, it is not a specific hallmark manifestation. Xerostomia (choice D) is not a primary symptom associated with Parkinson's disease.
2. A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?
- A. Administer it intramuscularly
- B. Monitor APTT levels
- C. Give it in the abdomen
- D. Administer rapidly
Correct answer: C
Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.
3. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?
- A. Blood pressure
- B. Complete blood count
- C. Serum phenytoin levels
- D. Liver function tests
Correct answer: C
Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.
4. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?
- A. Blood glucose of 160 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic BP of 140 mm Hg
- D. Respiratory rate of 20/min
Correct answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.
5. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?
- A. Apologize to the others for your behavior.
- B. I am disappointed that you continue to act out when you are angry.
- C. Come outside with me for a walk.
- D. If you don't calm down, you will have to go into seclusion.
Correct answer: C
Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.
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