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PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?
- A. Dry, cracked lips
- B. Bleeding gums
- C. Foul-smelling breath
- D. Red, open sores in the mouth
Correct answer: D
Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.
2. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct answer: C
Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.
3. A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?
- A. I steal things because it’s the only way I can keep my mind off my bad marriage
- B. I can’t believe I was accused of something I didn’t do
- C. I don’t want to talk about my feelings right now; we will talk more next time
- D. I think that people should earn money honestly, even though I stole
Correct answer: D
Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.
4. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?
- A. Monitor for liver function
- B. It can cause muscle pain
- C. It is safe to take during pregnancy
- D. Both A and B
Correct answer: D
Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.
5. A charge nurse is evaluating the time management skills of a newly licensed nurse. The charge nurse should intervene when the newly licensed nurse does which of the following?
- A. Re-evaluates priorities halfway through the shift
- B. Delegates changing a sterile dressing to a licensed practical nurse
- C. Groups activities for the same client
- D. Works on several tasks simultaneously
Correct answer: D
Rationale: The correct answer is D. Working on several tasks simultaneously may lead to errors due to divided attention and lack of focus. It is important for nurses to prioritize tasks and complete them one at a time to ensure thoroughness and accuracy. Choices A, B, and C are appropriate time management strategies. Re-evaluating priorities, delegating tasks appropriately, and grouping activities for the same client can help improve efficiency and quality of care.
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