a nurse is planning care to prevent complications in a client with immobility which of the following interventions should the nurse include a nurse is planning care to prevent complications in a client with immobility which of the following interventions should the nurse include
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form B

1. A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?

Correct answer: B

Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation. Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot. Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones. Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.

2. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

3. A nurse is caring for a client prescribed the HMG CoA reductase inhibitor, atorvastatin. Which of the following should be monitored while this medication is prescribed?

Correct answer: A

Rationale: Corrected Rationale: Atorvastatin, an HMG CoA reductase inhibitor, can lead to hepatotoxicity. Therefore, monitoring liver function through regular tests is essential. Baseline liver function should be assessed, followed by tests at 12 weeks after starting therapy and periodically thereafter. This monitoring helps detect early signs of liver damage, including jaundice, nausea, and dark urine. Incorrect Choices Rationale: B) Renal function test is not directly affected by atorvastatin. C) Hearing screenings and D) Visual acuity screenings are not indicated for monitoring while on atorvastatin therapy.

4. Most fat replacers are made from:

Correct answer: B

Rationale: Most fat replacers are made from carbohydrates. Carbohydrates are utilized to mimic the texture of fats in food products. Proteins (Choice A) are not commonly used as fat replacers and are more often associated with other functions in food. Cholesterol (Choice C) is a type of fat and not used to replace fat in food products. Monoglycerides (Choice D) are sometimes used as emulsifiers or stabilizers in food products but are not the primary source of fat replacers.

5. A healthcare professional is providing information to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the healthcare professional include? (Select all that apply)

Correct answer: C

Rationale: Performing the pelvic rock exercise daily can help relieve backache during pregnancy by strengthening the back and abdominal muscles, providing support to the spine. This exercise is beneficial in maintaining proper posture and reducing strain on the back. Avoiding standing for prolonged periods can also help alleviate backache by reducing pressure on the spine and supporting muscles. Kegel exercises primarily focus on strengthening the pelvic floor muscles and may not directly help with backache during pregnancy. Avoiding any lifting is overly restrictive and not necessary, as long as proper lifting techniques are followed.

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