ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?
- A. Ventrogluteal
- B. Deltoid
- C. Dorsogluteal
- D. Vastus lateralis
Correct answer: D
Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.
2. A healthcare professional is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the healthcare professional include?
- A. Administer the injection into the abdomen.
- B. Avoid massaging the injection site after administration.
- C. Expect mild bruising at the injection site.
- D. Avoid alternating injection sites between the arms.
Correct answer: A
Rationale: Administering enoxaparin into the abdomen is recommended to ensure proper absorption and effectiveness. Massaging the injection site after administration should be avoided as it can increase the risk of bleeding or bruising. Mild bruising at the injection site is common with enoxaparin and should be expected. Alternating injection sites, especially between arms, is not suitable for enoxaparin administration. Consistent administration into the abdomen is preferred for consistent absorption of the medication.
3. Which of the following demonstrates intersectoral linkages?
- A. Two-way referral system
- B. Team approach
- C. Endorsement by a midwife to another midwife
- D. Cooperation between public health nurse and public school teacher
Correct answer: D
Rationale: Intersectoral linkages involve collaborations between the health sector and other sectors for community development. In this scenario, cooperation between a public health nurse (PHN) and a public school teacher exemplifies intersectoral linkages, as it represents a partnership between the health and education sectors.
4. A client with a history of chronic heart failure is being discharged. Which instruction should the nurse include in the discharge teaching?
- A. Weigh yourself daily and report a weight gain of 2 pounds or more in a day.
- B. Restrict fluid intake to 2000 mL per day.
- C. Increase your salt intake to prevent electrolyte imbalance.
- D. Exercise vigorously at least three times a week.
Correct answer: A
Rationale: The correct answer is to weigh yourself daily and report a weight gain of 2 pounds or more in a day. This instruction is crucial because daily weights help in early detection of fluid retention, a common complication in heart failure. Monitoring weight is essential for managing heart failure and preventing exacerbations. Choice B is incorrect because fluid restriction may be necessary in some cases of heart failure, but a general limit of 2000 mL per day is not appropriate without individual assessment. Choice C is incorrect as increasing salt intake can worsen fluid retention and exacerbate heart failure symptoms. Choice D is incorrect because while exercise is beneficial for heart health, vigorous exercise may not be suitable for all heart failure patients and should be tailored to their specific condition.
5. A nurse is working in an acute care mental health facility and is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
- A. All-or-nothing thinking.
- B. Euphoric mood.
- C. Disorganized speech.
- D. Hypochondriasis.
Correct answer: C
Rationale: The correct answer is C: Disorganized speech. Disorganized speech is a hallmark symptom of schizophrenia, characterized by impaired thought processes that lead to incoherent, disjointed communication. All-or-nothing thinking (Choice A) is more commonly associated with cognitive distortions seen in conditions like anxiety disorders. Euphoric mood (Choice B) is not a typical finding in schizophrenia, as individuals with this disorder often display a flat or blunted affect. Hypochondriasis (Choice D) involves a preoccupation with having a serious illness and is not a primary symptom of schizophrenia.
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