a nurse is performing a change of shift assessment on four clients which finding should the nurse report to the provider first
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form B

1. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?

Correct answer: B

Rationale: Lethargy and confusion in a client with gastroenteritis are concerning findings that may indicate severe dehydration or electrolyte imbalance, requiring immediate intervention. While the other options are important, they do not pose an immediate life-threatening risk compared to the altered mental status in a client with gastroenteritis.

2. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which site is safest for the nurse to use?

Correct answer: A

Rationale: The correct answer is 'Ventrogluteal.' The ventrogluteal site is recommended for intramuscular injections in adults because it is free of major blood vessels and nerves, reducing the risk of injury or complications. Choice B, 'Dorsogluteal,' is not recommended due to the proximity of the sciatic nerve and major blood vessels. Choices C and D, 'Vastus lateralis' and 'Rectus femoris,' are sites commonly used for intramuscular injections but are more suitable for pediatric or specific population groups, not typically for adults.

3. A client is being educated by a nurse about the use of bupropion. Which of the following should be included?

Correct answer: B

Rationale: The correct answer is B. Bupropion may lower the seizure threshold, increasing the risk of seizures, especially in clients with a history of seizures. Choice A is incorrect because bupropion is associated with weight loss rather than weight gain. Choice C is incorrect as bupropion is not an SSRI; it is an aminoketone antidepressant. Choice D is incorrect as bupropion, like all medications, can have side effects, and it is essential for clients to be aware of them.

4. A nurse is providing teaching to a client who is at 34 weeks of gestation and is scheduled for a nonstress test. Which of the following statements should the nurse plan to make?

Correct answer: B

Rationale: The correct statement for the nurse to make is choice B, 'You should expect the test to take about 30 minutes.' The nonstress test is used to assess fetal well-being by monitoring fetal heart rate in response to movements. Choice A is incorrect because medications are not typically administered during a nonstress test. Choice C is incorrect as there is no need for the client to fast before the test. Choice D is incorrect because determining fetal lung maturity is usually done through other tests, not the nonstress test.

5. A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Bradykinesia. Bradykinesia, which refers to slowness of movement, is a characteristic symptom of Parkinson's disease. Other common manifestations in Parkinson's disease include tremors, muscle rigidity, orthostatic hypotension, and drooling. Pruritus (choice A) is unrelated to Parkinson's disease. While hypertension (choice B) can coexist with Parkinson's disease due to autonomic dysfunction, it is not a specific hallmark manifestation. Xerostomia (choice D) is not a primary symptom associated with Parkinson's disease.

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