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 client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?
- A. Fetal heart rate 100/min
- B. Weakened uterine contractions
- C. Enhanced production of fetal lung surfactant
- D. Maternal blood glucose 63 mg/dL
Correct answer: B
Rationale: Terbutaline is a tocolytic medication that works by relaxing the uterine muscles, leading to weakened uterine contractions. This effect helps to prevent preterm labor. Therefore, the nurse should expect weakened uterine contractions in a client who has received terbutaline at 28 weeks of gestation. Choices A, C, and D are incorrect. Terbutaline administration would not directly affect the fetal heart rate, enhance fetal lung surfactant production, or cause maternal hypoglycemia.
3. A client has a new prescription for amitriptyline. Which of the following instructions should the nurse include?
- A. Take the medication in the morning.
- B. Avoid consuming grapefruit juice.
- C. Take the medication with a full glass of water.
- D. Monitor for signs of weight gain.
Correct answer: C
Rationale: When a client is prescribed amitriptyline, it is important to instruct them to take the medication with a full glass of water. This instruction helps prevent esophageal irritation, as amitriptyline can be harsh on the esophagus. Option C is the correct choice. Option A, taking the medication in the morning, is not specific to amitriptyline and can vary depending on the individual's condition. Option B, avoiding grapefruit juice, is a general precaution for many medications but not specifically related to amitriptyline. Option D, monitoring for signs of weight gain, is not a direct instruction for taking the medication itself and may not be a common side effect of amitriptyline.
4. What are the key nursing interventions for a patient receiving diuretic therapy?
- A. Monitor electrolyte levels and administer potassium as needed
- B. Restrict fluid intake and provide a low-sodium diet
- C. Encourage oral fluids and increase dietary potassium
- D. Provide high-sodium foods to improve electrolyte balance
Correct answer: A
Rationale: The correct answer is A: Monitor electrolyte levels and administer potassium as needed. Patients on diuretic therapy are at risk of electrolyte imbalances, particularly low potassium levels. Monitoring electrolytes and administering potassium as needed are crucial nursing interventions to prevent imbalances. Choice B is incorrect because restricting fluid intake and providing a low-sodium diet are not typically indicated for patients on diuretic therapy. Choice C is incorrect as encouraging oral fluids and increasing dietary potassium can exacerbate electrolyte imbalances in patients on diuretics. Choice D is incorrect as providing high-sodium foods would worsen electrolyte balance issues in patients on diuretic therapy.
5. A patient is admitted with a diagnosis of myasthenia gravis. What symptom should the nurse expect to find during the assessment?
- A. Joint pain
- B. Muscle weakness
- C. Loss of sensation
- D. Severe headache
Correct answer: B
Rationale: Myasthenia gravis is a neuromuscular disorder characterized by muscle weakness and fatigue, especially in the voluntary muscles. Patients with myasthenia gravis commonly experience weakness in muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. This weakness typically worsens with activity and improves with rest. Joint pain, loss of sensation, and severe headaches are not typical symptoms of myasthenia gravis. Therefore, the correct answer is muscle weakness (choice B) as it aligns with the characteristic symptom of myasthenia gravis.
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