ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. During triage following a mass casualty event, which client should be prioritized?
- A. A client with massive head trauma
- B. A client with full-thickness burns to the face and trunk
- C. A client showing signs of hypovolemic shock
- D. A client with an open fracture of the lower extremity
Correct answer: C
Rationale: During triage after a mass casualty event, the client showing signs of hypovolemic shock should be prioritized. Hypovolemic shock is a life-threatening condition that requires immediate attention to restore circulation and prevent death. While clients with head trauma, burns, and fractures also need urgent care, hypovolemic shock poses an immediate threat to life and must be addressed first to stabilize the client's condition.
2. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsening with deep breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.
3. When advising a woman considering pregnancy on nutritional needs to reduce the risk of giving birth to a newborn with a neural tube defect, what information should the nurse include?
- A. Limit alcohol consumption.
- B. Increase intake of iron-rich foods.
- C. Consume foods fortified with folic acid.
- D. Avoid foods containing aspartame.
Correct answer: C
Rationale: The correct answer is C: Consume foods fortified with folic acid. Folic acid plays a crucial role in preventing neural tube defects. It is advised to consume foods fortified with folic acid or take a supplement containing at least 400 micrograms of folic acid daily. This nutrient is essential for the developing fetus and can significantly reduce the risk of neural tube defects when taken before and during early pregnancy. Choices A, B, and D are incorrect. While limiting alcohol consumption is important during pregnancy, it is not directly related to reducing the risk of neural tube defects. Increasing intake of iron-rich foods is essential for preventing anemia but is not specifically linked to neural tube defects. Avoiding foods containing aspartame is generally recommended, but it is not directly related to reducing the risk of neural tube defects.
4. A client has hyperthermia. Which of the following actions should the nurse take?
- A. Submerge the client's feet in ice water.
- B. Cover the client with a thermal blanket.
- C. Administer oral acetaminophen.
- D. Initiate seizure precautions.
Correct answer: C
Rationale: Administering oral acetaminophen is the appropriate intervention for a client with hyperthermia. Acetaminophen helps to reduce fever by lowering the body's temperature. Submerging the client's feet in ice water can lead to shock and is not recommended. Using a thermal blanket may worsen the condition by trapping heat. Initiating seizure precautions is not directly related to managing hyperthermia.
5. A nurse is teaching about measures to promote sleep with insomnia. What statement indicates understanding?
- A. Take naps throughout the day
- B. Reduce fluid intake 2 hours before bedtime
- C. Drink coffee to help stay awake
- D. Increase screen time before bed
Correct answer: B
Rationale: The correct answer is B. Reducing fluid intake before bedtime helps prevent interruptions in sleep due to bathroom visits, which is crucial for individuals with insomnia. Taking naps throughout the day (choice A) may disrupt nighttime sleep. Drinking coffee (choice C) is counterproductive as it contains caffeine, which can interfere with falling asleep. Increasing screen time before bed (choice D) can negatively impact sleep quality due to the stimulating effects of screens.
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