ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A client with a closed head injury has their eyes open when pressure is applied to the nail beds, and they exhibit adduction of the arms with flexion of the elbows and wrists. The client also moans with stimulation. What is the client's Glasgow Coma Score?
- A. 4
- B. 7 (comatose)
- C. 9
- D. 10
Correct answer: B
Rationale: The client's Glasgow Coma Score is 7. This is calculated by assigning 2 points for eye-opening to pain, 2 points for incomprehensible sounds, and 3 points for flexion posturing. Choices A, C, and D are incorrect. Choice A (4) would be the score if the client displayed decerebrate posturing instead of flexion posturing. Choice C (9) would be the score if the client exhibited eye-opening to speech, confused speech, and decorticate posturing. Choice D (10) would be the score if the client showed eye-opening spontaneously, oriented speech, and obeyed commands, which is not the case here.
2. In which of the following situations would the use of physical restraints most likely be justified?
- A. Mr. Y is agitated and aggressive while experiencing severe alcohol withdrawal and is not responding to chemical sedation.
- B. Mrs. U, diagnosed with dementia, was found wandering outside the hospital, and nurses have been unable to redirect her to stay on the unit.
- C. Mr. I is delirious during the acute stage of his urinary tract infection and is ringing the call bell nearly continuously.
- D. Mrs. T is frequently entering other patients' rooms and attempting to crawl into others' beds.
Correct answer: A
Rationale: Answer A is the correct choice because it describes a situation where the client poses a risk due to agitation and aggression during severe alcohol withdrawal, and chemical sedation has not been effective. In such cases, physical restraints may be justified as a last resort to ensure the safety of the client and others. Choices B, C, and D present scenarios where alternative strategies like redirection, addressing delirium, or implementing behavioral interventions should be attempted before considering physical restraints.
3. What is the most important intervention for a client with delirium?
- A. Administer sedative medication
- B. Identify any reversible causes of delirium
- C. Provide a low-stimulation environment
- D. Increase environmental stimulation
Correct answer: B
Rationale: The correct answer is to identify any reversible causes of delirium. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. Addressing these underlying causes can help resolve delirium. Administering sedative medication (Choice A) can worsen delirium by further altering mental status. Providing a low-stimulation environment (Choice C) is helpful to manage delirium symptoms, but it is not the most important intervention. Increasing environmental stimulation (Choice D) is contraindicated in delirium as it can exacerbate confusion and agitation.
4. During lactation, where is lactose synthesized in the body?
- A. Liver
- B. Breast
- C. Kidney
- D. Pancreas
Correct answer: B
Rationale: The correct answer is B: Breast. Lactose is synthesized in the breast during lactation to produce breastmilk. The liver is responsible for various metabolic functions but does not synthesize lactose. The kidney's primary role is in filtering blood and regulating electrolytes, not lactose synthesis. The pancreas is involved in producing digestive enzymes and insulin, not lactose synthesis.
5. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct answer: B
Rationale: The priority action for the nurse in this situation is to position the client with one hip elevated. This position can help improve blood flow to the placenta and stabilize blood pressure, which is crucial for both the client and the fetus during labor. It can also help optimize fetal oxygenation by improving circulation. Notifying the provider of the findings may be necessary, but ensuring proper positioning of the client takes precedence to address the immediate physiological needs. Asking the client about pain medication or having the client void are important interventions but are not the priority in this scenario where the client is experiencing painful contractions and has low blood pressure.
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