ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client had a pituitary tumor removed. Which of the following findings requires further assessment?
- A. Glasgow scale score of 15
- B. Blood drainage on dressing measuring 3 cm
- C. Report of dry mouth
- D. Urinary output greater than fluid intake
Correct answer: D
Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.
2. What should a healthcare professional prioritize when managing a client with delirium?
- A. Administering sedative medication
- B. Providing a low-stimulation environment
- C. Identifying the underlying cause of the delirium
- D. Controlling behavioral symptoms with medication
Correct answer: C
Rationale: When managing a client with delirium, the priority should be to identify the underlying cause of the delirium. Delirium can result from various triggers such as infections, medication side effects, or metabolic imbalances. By determining the root cause, healthcare professionals can provide targeted treatment and improve outcomes. Administering sedative medication (Choice A) could exacerbate delirium as these drugs can worsen confusion. While providing a low-stimulation environment (Choice B) is beneficial, it is not as critical as identifying the cause. Controlling behavioral symptoms with medication (Choice D) should only be considered after identifying and addressing the underlying cause of delirium.
3. Cholecystokinin (CCK) is produced in the:
- A. duodenum.
- B. stomach.
- C. pancreas.
- D. liver.
Correct answer: A
Rationale: Cholecystokinin (CCK) is produced in the duodenum, not the stomach, pancreas, or liver. It is released in response to the presence of food in the duodenum, where it plays a crucial role in regulating digestive processes by stimulating the release of bile from the gallbladder and enzymes from the pancreas. Therefore, the correct answer is the duodenum (Choice A). Choices B, C, and D are incorrect because CCK is not produced in the stomach, pancreas, or liver.
4. During preterm labor, a client is scheduled for an amniocentesis. The nurse should review which of the following tests to assess fetal lung maturity?
- A. Alpha-fetoprotein (AFP)
- B. Lecithin/sphingomyelin (L/S) ratio
- C. Kleihauer-Betke test
- D. Indirect Coombs' test
Correct answer: B
Rationale: The Lecithin/sphingomyelin (L/S) ratio is a test used to evaluate fetal lung maturity. An L/S ratio greater than 2:1 indicates fetal lung maturity. This test helps in determining the risk of respiratory distress syndrome in the newborn. Alpha-fetoprotein (AFP) is used in screening for neural tube defects, not for assessing lung maturity. The Kleihauer-Betke test is used to detect fetal-maternal hemorrhage, not fetal lung maturity. The Indirect Coombs' test is used to identify the presence of antibodies in the mother's blood that could attack fetal red blood cells, not for assessing lung maturity.
5. When assessing a 5-year-old boy with major trauma, his blood pressure is 70/40 mm Hg, and his pulse rate is 140 beats/min and weak. The child's blood pressure:
- A. indicates decompensated shock.
- B. reflects adequate compensation.
- C. suggests increased intracranial pressure.
- D. is appropriate based on his age.
Correct answer: A
Rationale: In a 5-year-old boy with major trauma, a blood pressure of 70/40 mm Hg and a pulse rate of 140 beats/min, and weak, indicate decompensated shock. This presentation signifies inadequate perfusion, leading to compensatory mechanisms being overwhelmed, resulting in decompensated shock. Choice B is incorrect as the vital signs suggest the body is unable to adequately compensate for the trauma. Choice C is incorrect as the vital signs are more indicative of shock rather than increased intracranial pressure. Choice D is incorrect as such low blood pressure is not appropriate for a child of this age and indicates a critical condition.
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