ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
- A. Diaphoresis
- B. Polyuria
- C. Abdominal pain
- D. Thirst
Correct answer: A
Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.
2. CHN is a community-based practice. What best explains this statement?
- A. The service is provided in the natural environment of people
- B. The nurse conducts community diagnosis to determine nursing needs and problems
- C. The services are based on the available resources within the community
- D. Priority setting is based on the magnitude of the health problems identified
Correct answer: B
Rationale: In community-based practice, healthcare providers deliver care to individuals in their natural environments, such as homes, schools, and workplaces. Conducting community diagnosis allows nurses to assess the specific needs and problems within the community, enabling them to tailor their services effectively and address the identified health concerns.
3. Which is the correct method for teaching a client to use a cane when they have left-leg weakness?
- A. Use the cane on the weaker side of the body
- B. Advance the cane and the strong leg together
- C. Maintain two points of support on the floor at all times
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct answer: C
Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.
4. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?
- A. Amnesia
- B. Hypervigilance
- C. Hallucinations
- D. Severe agitation
Correct answer: B
Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.
5. What is the priority nursing intervention for a patient with chest pain?
- A. Administer nitroglycerin
- B. Assess pain level
- C. Monitor vital signs
- D. Provide oxygen therapy
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.
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