ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?
- A. Feelings of dread
- B. Rapid speech
- C. Purposeless activity
- D. Heightened perceptual field
Correct answer: D
Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.
2. What is the most important intervention to decrease the stressors of hospitalization for a 9-month-old infant being treated for a bacterial infection?
- A. Encourage the infant's parents to remain at the bedside and actively participate in the infant's care.
- B. Provide a brightly lit environment for the infant.
- C. Play tapes of the mother's voice.
- D. Assign the same nurse to the infant as much as possible.
Correct answer: A
Rationale: Encouraging the infant's parents to remain at the bedside and actively participate in the infant's care is crucial in decreasing the stressors of hospitalization for the infant. Parental presence provides comfort and security, promotes bonding, and maintains a sense of familiarity for the infant during a potentially stressful situation. This involvement can help reduce anxiety and promote better outcomes for the infant's emotional well-being and overall hospital experience. Providing a brightly lit environment (choice B) can actually increase stress for the infant, as infants generally prefer dimly lit environments for better sleep. Playing tapes of the mother's voice (choice C) may offer some comfort but does not substitute for parental presence. While assigning the same nurse to the infant (choice D) can provide continuity of care, it is not as effective as having the parents present for emotional support and bonding.
3. A breastfeeding mother reports to the nurse that her newborn nurses every hour and never seems satisfied. Which advice should the nurse provide?
- A. Supplement breastfeeding with formula after each nursing session.
- B. Allow the newborn to nurse on each breast for at least 20 minutes.
- C. Reduce the number of nursing sessions to every 2-3 hours.
- D. Ensure the newborn has a proper latch and is effectively nursing.
Correct answer: D
Rationale: The nurse should ensure that the newborn has a proper latch and is effectively nursing. Sometimes, newborns nurse frequently for comfort even when they are effectively latched. It is essential to address the latch first before considering other interventions. Supplementing with formula (Choice A) may decrease the mother's milk supply. Allowing the newborn to nurse for a set time (Choice B) may not address the underlying latch issue. Reducing nursing sessions (Choice C) may lead to decreased milk production and does not address the latch problem.
4. A nurse is caring for a client prescribed clopidogrel. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Blood pressure
- C. Potassium levels
- D. Respiratory rate
Correct answer: A
Rationale: Corrected Rationale: Clopidogrel is an antiplatelet medication, so the nurse should monitor for signs of bleeding and liver function tests due to potential liver effects. Monitoring liver function tests is essential to detect any adverse effects on the liver because clopidogrel can cause hepatotoxicity. While monitoring blood pressure, potassium levels, and respiratory rate are important in general patient care, they are not the priority assessments specifically related to clopidogrel use.
5. What are the small, fingerlike projections into the intestinal lumen called?
- A. Villi
- B. Goblets
- C. Lacteals
- D. Polyps
Correct answer: A
Rationale: The correct answer is A: Villi. Villi are small fingerlike projections in the intestine that increase the surface area for nutrient absorption. Goblets (choice B) are mucus-secreting cells in the intestines. Lacteals (choice C) are lymphatic vessels in the small intestine that absorb dietary fats. Polyps (choice D) are abnormal tissue growths.
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