ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct answer: B
Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Neonates with neonatal abstinence syndrome often display irritability, tremors, and feeding difficulties. Hyporeactivity, acrocyanosis, and a respiratory rate of 50/min are not typical manifestations of neonatal abstinence syndrome. Hyporeactivity is more associated with conditions like hypothyroidism or sepsis, acrocyanosis is a common finding in newborns due to immature peripheral circulation, and a respiratory rate of 50/min is within the normal range for a newborn.
2. A healthcare provider is providing education to a client about atorvastatin. Which of the following should be included?
- A. Monitor for muscle pain
- B. Avoid sun exposure
- C. Report any gastrointestinal symptoms
- D. Check liver function tests
Correct answer: A
Rationale: Corrected Rationale: Atorvastatin can cause muscle pain and liver function abnormalities. Monitoring for muscle pain is essential as it can be a sign of a serious side effect called rhabdomyolysis. While liver function tests are necessary before starting atorvastatin, checking them continuously may not be required. Avoiding sun exposure and reporting gastrointestinal symptoms are not directly associated with atorvastatin use.
3. When assessing a patient with major depressive disorder, which of the following is a common cognitive symptom?
- A. Hallucinations
- B. Delusions
- C. Lack of appetite
- D. Negative self-talk
Correct answer: D
Rationale: Negative self-talk is a common cognitive symptom of major depressive disorder. It involves a pattern of negative thoughts and beliefs about oneself, which can significantly impact a patient's self-esteem and overall outlook on life. Hallucinations and delusions are more commonly associated with other mental health conditions like schizophrenia, while lack of appetite is typically considered a physical symptom of depression rather than a cognitive one.
4. A client has a prescription for a clear liquid diet. Which of the following foods should the nurse offer?
- A. Milk
- B. Vegetable juice
- C. Chicken broth
- D. Orange juice with pulp
Correct answer: C
Rationale: A clear liquid diet consists of easily digestible transparent liquids. Chicken broth is an appropriate choice as it meets the criteria of being clear and liquid, making it suitable for a clear liquid diet. Milk, vegetable juice, and orange juice with pulp are not considered clear liquids. Milk is not transparent, vegetable juice is not clear, and orange juice with pulp contains solid particles, all of which do not align with the requirements of a clear liquid diet.
5. A client prescribed allopurinol for gout is being taught by a nurse. Which of the following should be included in the teaching?
- A. Take the medication with meals.
- B. Drink at least 2 liters of water per day.
- C. Avoid foods high in purines.
- D. Increase your dietary intake of calcium.
Correct answer: B
Rationale: The correct answer is B: 'Drink at least 2 liters of water per day.' Clients taking allopurinol should be instructed to drink plenty of water to prevent kidney stones, a potential side effect of the medication. Option A is incorrect because allopurinol is usually taken without regard to meals. Option C is not directly related to the teaching about allopurinol, as it pertains more to dietary management of gout. Option D is also unrelated to allopurinol use for gout.
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