ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?
- A. Constricted pupils
- B. Dilated pupils
- C. Increased reflexes
- D. Elevated blood pressure
Correct answer: A
Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.
2. A nurse is caring for a patient whose family member requests to view the patient’s medical record. What response should the nurse make?
- A. “The patient should provide permission to share the records with you.â€
- B. “You can view the records if the provider approves it.â€
- C. “I will allow you to see the chart if the patient is unable to give consent.â€
- D. “You need to fill out a request form.â€
Correct answer: A
Rationale: In this scenario, the nurse should respond by indicating that the patient needs to provide permission to share their medical records with the family member. Patient confidentiality is a fundamental principle in healthcare, and sharing medical records without the patient's consent is a violation of privacy. Choice B is incorrect because the provider's approval alone is not sufficient to share medical records, as patient consent is crucial. Choice C is incorrect because viewing the patient's chart without the patient's consent is not appropriate. Choice D is incorrect as filling out a request form does not address the issue of patient consent, which is essential for sharing medical information.
3. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?
- A. Bounding pulse
- B. Conjunctival pallor
- C. Elevated blood pressure
- D. Glossitis
Correct answer: B
Rationale: The correct answer is B: Conjunctival pallor. In anemia, there is a decrease in hemoglobin levels, leading to paleness of the conjunctiva. This is a common finding in individuals with anemia. Bounding pulse (choice A) is not typically associated with anemia but can be seen in conditions like hyperthyroidism. Elevated blood pressure (choice C) is not a common finding in anemia; instead, blood pressure may be low due to decreased oxygen-carrying capacity. Glossitis (choice D), or a swollen tongue, can be seen in certain types of anemia but is not as specific or common as conjunctival pallor.
4. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?
- A. Limit stair climbing for the first few weeks
- B. Avoid lifting anything heavier than the newborn
- C. Use a pillow to support the abdomen when coughing or sneezing
- D. All of the above
Correct answer: D
Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.
5. A nurse is providing dietary teaching to a client who is at risk for cardiovascular disease. Which of the following foods should the nurse recommend?
- A. Fried chicken
- B. Oatmeal
- C. Bacon
- D. Whole milk
Correct answer: B
Rationale: Oatmeal is high in fiber, which helps lower cholesterol levels, making it a heart-healthy food option for clients at risk for cardiovascular disease. Fried chicken, bacon, and whole milk are high in saturated fats and cholesterol, which can increase the risk of heart disease and should be limited in the diet of individuals at risk for cardiovascular issues.
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