ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL per hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct answer: B
Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.
2. A nurse is assessing a client who was brought to the psychiatric emergency services by law enforcement. The client has disorganized, incoherent speech with loose associations and religious content. The nurse should recognize these signs and symptoms as consistent with which of the following?
- A. Alzheimer's disease
- B. Schizophrenia
- C. Substance intoxication
- D. Depression
Correct answer: B
Rationale: The correct answer is B: Schizophrenia. Disorganized speech, loose associations, and religious delusions are characteristic symptoms of schizophrenia. In this scenario, the client's presentation aligns with positive symptoms of schizophrenia, indicating a severe mental disorder requiring immediate attention. Choice A, Alzheimer's disease, primarily involves cognitive decline and memory impairment, not disorganized speech or religious content. Choice C, Substance intoxication, may present with altered mental status but typically lacks the persistent pattern of symptoms seen in schizophrenia. Choice D, Depression, is associated with a different set of symptoms such as low mood, anhedonia, and changes in appetite or sleep, rather than disorganized speech and loose associations.
3. Where does the absorption of most nutrients occur?
- A. Large intestine.
- B. Small intestine.
- C. Stomach.
- D. Mouth.
Correct answer: B
Rationale: The absorption of most nutrients occurs in the small intestine. This is where digested food is broken down further and absorbed into the bloodstream through the intestinal walls. The large intestine primarily absorbs water and electrolytes, while the stomach mainly aids in digestion by breaking down food with gastric juices. The mouth is responsible for the initial mechanical breakdown of food through chewing and the enzymatic action of saliva, but absorption does not occur there.
4. A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?
- A. Increased physical activity
- B. Lowered immune system function
- C. Regular health screenings
- D. Proper nutrition
Correct answer: B
Rationale: The correct answer is B: Lowered immune system function. In older adults, a decline in immune system function increases the risk of developing infections. Increased physical activity (choice A) and proper nutrition (choice D) generally support immune function and overall health, reducing the risk of infections. Regular health screenings (choice C) are important for early detection of health issues but do not directly increase the risk of infections.
5. What is the best reason for administering vitamin A to a postpartum client?
- A. To help strengthen her immune system
- B. To improve her vision
- C. To protect her from infection
- D. To promote wound healing
Correct answer: A
Rationale: Vitamin A is crucial for maintaining the integrity of epithelial tissues, which are the body's first line of defense against pathogens. By supporting the immune system, vitamin A helps protect the postpartum client from infections and promotes overall health.
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