ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct answer: A
Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.
2. Signs of malnutrition can appear when:
- A. nutrient reserves are depleted.
- B. nutrient intake exceeds daily needs.
- C. energy intake is restricted.
- D. caloric expenditure increases.
Correct answer: A
Rationale: The correct answer is A: 'nutrient reserves are depleted.' Signs of malnutrition manifest when the body's reserves of essential nutrients are exhausted and can no longer sustain health. Choice B is incorrect because excessive nutrient intake exceeding daily needs does not lead to malnutrition but may cause other health issues. Choice C is incorrect as restricting energy intake may lead to weight loss but not necessarily malnutrition. Choice D is also incorrect as increasing caloric expenditure does not directly cause malnutrition.
3. The nurse is caring for a patient transferred from the local prison who was arrested and convicted of child sexual abuse. The nurse feels disgust for the patient's behavior but can avoid being judgmental by understanding what?
- A. Motivation
- B. State laws
- C. The patient's social history
- D. Code of ethics
Correct answer: A
Rationale: In this scenario, the nurse is experiencing negative emotions towards the patient's behavior. By understanding the patient's motivation, the nurse can gain insight into the underlying factors that led to the behavior, helping to avoid being judgmental. This approach allows the nurse to provide care and support without letting personal feelings interfere. Understanding motivation can also aid in developing a therapeutic relationship and providing appropriate care tailored to the patient's needs. Choices B, C, and D are incorrect as while state laws, the patient's social history, and the code of ethics are important aspects to consider in healthcare, they do not directly address the nurse's feelings of disgust and the need to avoid being judgmental towards the patient's behavior.
4. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a duration of 90 seconds, and the fetal heart rate is 170-180/minute. Which of the following actions should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: In this scenario, the contractions are too frequent (tachysystole), and the fetal heart rate is elevated. Tachysystole can lead to decreased oxygen perfusion to the fetus, causing fetal distress. Therefore, the correct action for the nurse to take is to discontinue the oxytocin infusion to prevent harm to both the mother and fetus. Increasing or maintaining the oxytocin infusion would exacerbate the current situation, potentially leading to further complications. Decreasing the oxytocin infusion may not be sufficient to address the tachysystole and elevated fetal heart rate, making it an inappropriate choice.
5. A healthcare professional is assessing a client who has a new prescription for levothyroxine. Which of the following findings should the healthcare professional report to the provider?
- A. Weight gain
- B. Increased heart rate
- C. Heat intolerance
- D. Elevated blood pressure
Correct answer: C
Rationale: The correct answer is C: Heat intolerance. Heat intolerance is a concerning sign of levothyroxine toxicity and should be reported to the provider promptly. Levothyroxine is a medication used to treat hypothyroidism by supplementing the body's thyroid hormones. When a client experiences heat intolerance, it can indicate that the dose of levothyroxine is too high, leading to hyperthyroidism symptoms. Weight gain, increased heart rate, and elevated blood pressure are not typically associated with levothyroxine toxicity; instead, they are more commonly seen in conditions like hypothyroidism.
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