ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct answer: C
Rationale: In clients with schizophrenia, poor problem-solving ability is a common assessment finding due to impaired cognitive function associated with the disorder. This impairment can manifest as difficulties in decision-making and problem-solving. Choice A, decreased level of consciousness, is not a typical finding in schizophrenia. Choice B, inability to identify common objects, is more indicative of conditions like dementia rather than schizophrenia. Choice D, preoccupation with somatic disturbances, is more characteristic of somatic symptom disorder rather than schizophrenia.
2. A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?
- A. Administer it intramuscularly
- B. Monitor APTT levels
- C. Give it in the abdomen
- D. Administer rapidly
Correct answer: C
Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.
3. A client with hepatic encephalopathy is being educated about their diet by a nurse. Which of the following food selections indicates that the client understands the teaching?
- A. A sandwich and a milkshake
- B. Rice with black beans
- C. Cottage cheese and tuna on lettuce
- D. A three-egg omelet with low-sodium ham
Correct answer: B
Rationale: The correct answer is B: Rice with black beans. Clients with hepatic encephalopathy should limit protein intake to prevent the buildup of ammonia. Plant-based proteins are preferred over animal-based proteins in this condition. Rice with black beans provides a good balance of nutrients and is a suitable choice for a client with hepatic encephalopathy. Choices A, C, and D are incorrect because they contain animal-based proteins, which should be limited in clients with hepatic encephalopathy.
4. A client is receiving enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?
- A. Expel any air bubbles from the prefilled syringe
- B. Massage the injection site to aid in absorption of the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct answer: C
Rationale: The correct answer is to inject enoxaparin into the lateral abdominal wall for subcutaneous absorption. This site is commonly used for administering this type of medication. Expelling air bubbles from the syringe is not necessary and may result in a reduced dose being administered. Massaging the injection site is not recommended as it can lead to bruising or irritation. Administering an NSAID for injection site discomfort is not indicated as discomfort at the injection site is usually minimal and self-limiting.
5. A nurse is providing discharge instructions to a client after a myocardial infarction. Which of the following should be included?
- A. Resume normal activities immediately
- B. Monitor for chest pain and report any recurrence
- C. Avoid all physical activity for 6 months
- D. Take medications only as needed
Correct answer: B
Rationale: The correct answer is B: 'Monitor for chest pain and report any recurrence.' After a myocardial infarction, it is crucial for clients to be vigilant about any signs of chest pain as it could indicate a recurrent event. Prompt reporting of chest pain can lead to timely intervention, preventing further complications. Choice A is incorrect because resuming normal activities immediately after a heart attack can be dangerous and is not recommended. Choice C is also incorrect as avoiding all physical activity for 6 months is excessive and can lead to deconditioning. Choice D is incorrect as medications prescribed after a myocardial infarction are usually meant to be taken regularly as prescribed, not just as needed.
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