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 nurse is assessing a client who has schizophrenia and is experiencing negative symptoms. Which of the following findings should the nurse expect?
- A. Hallucinations
- B. Delusions
- C. Flat affect
- D. Paranoia
Correct answer: C
Rationale: The correct answer is C: Flat affect. Negative symptoms of schizophrenia involve deficits in normal emotional responses or other thought processes. These symptoms include a flat affect (reduced emotional expression), social withdrawal, and avolition (lack of motivation). Hallucinations and delusions are characteristic of positive symptoms, which involve the presence of abnormal behaviors or experiences. Paranoia is more associated with delusions rather than negative symptoms.
3. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?
- A. Glaucoma
- B. Hypertension
- C. Polycythemia
- D. Migraine headaches
Correct answer: A
Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.
4. A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. Malpractice
- D. Negligence
Correct answer: A
Rationale: The correct answer is A: Assault. Assault is the act of threatening a client with harm, such as the threat of using restraints to force-feed the client, even if no physical contact occurs. In this scenario, the statement made by the assistive personnel constitutes assault because it involves the threat of harm. Choice B, Battery, involves actual physical contact without the client's consent, which is not present in the scenario. Choice C, Malpractice, refers to professional negligence or misconduct, not a direct threat to the client. Choice D, Negligence, involves failure to provide reasonable care that results in harm, which is not applicable in this context.
5. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?
- A. Infection
- B. Airway obstruction
- C. Fluid imbalance
- D. Pain management
Correct answer: B
Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.
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