ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?
- A. Hypnosis promotes increased control of pain perception during labor
- B. Hypnosis uses therapeutic touch to reduce anxiety
- C. Hypnosis focuses on biofeedback as a relaxation technique
- D. Hypnosis provides instruction to minimize pain
Correct answer: A
Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.
2. A client is receiving digoxin therapy. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum electrolytes
- C. Blood pressure
- D. All of the above
Correct answer: D
Rationale: When a client is receiving digoxin therapy, it is crucial for the nurse to monitor liver function, serum electrolytes (especially potassium levels), and blood pressure. Digoxin is known to affect the heart's electrical activity and can lead to toxic effects if not managed properly. Monitoring liver function helps to assess the drug's metabolism and excretion. Checking serum electrolytes, especially potassium, is essential because digoxin toxicity can be exacerbated by electrolyte imbalances, particularly hypokalemia. Monitoring blood pressure is necessary because digoxin can influence cardiac contractility and heart rate, potentially affecting blood pressure. Therefore, monitoring all these parameters is vital to ensure the client's safety and therapeutic effectiveness of digoxin. Choices A, B, and C are incorrect because monitoring only one or two of these parameters may not provide a comprehensive assessment of the client's response to digoxin therapy.
3. A client newly diagnosed with osteoporosis is being taught by a nurse about preventing complications. Which food should the nurse recommend?
- A. Fried chicken
- B. Whole milk
- C. Oatmeal
- D. Bacon
Correct answer: C
Rationale: Oatmeal is an excellent recommendation for clients with osteoporosis due to its richness in fiber and nutrients, making it a heart-healthy and bone-friendly choice. Fried chicken (Choice A) is high in unhealthy fats and lacks the nutrients needed for bone health. Whole milk (Choice B) contains calcium but can be high in saturated fats, which may not be the best choice for individuals with osteoporosis. Bacon (Choice D) is high in saturated fats and sodium, which can have negative effects on bone health and overall well-being.
4. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?
- A. Encourage the client to focus on a distant object.
- B. Apply a warm compress to the client’s eyes.
- C. Recommend alternating eye patches during the day.
- D. Administer artificial tears.
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.
5. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel (AP)?
- A. Client who has chronic obstructive pulmonary disease and needs guidance with incentive spirometry
- B. Client who has awoken following a bronchoscopy and requests a drink
- C. Client who had a myocardial infarction 3 days ago and reports chest discomfort
- D. Client who had a cerebrovascular accident 2 days ago and needs help toileting
Correct answer: D
Rationale: The correct answer is D because the client who had a cerebrovascular accident 2 days ago and needs help toileting is stable and the task is appropriate for delegation to an assistive personnel (AP). Choices A, B, and C involve clients with more complex care needs that require the expertise of a nurse. Choice A involves providing guidance with incentive spirometry, which requires specialized knowledge and assessment skills. Choice B involves a client who has just undergone a bronchoscopy, so close monitoring is essential to assess for any complications. Choice C involves a client who had a myocardial infarction 3 days ago and is reporting chest discomfort, which could indicate a potential cardiac issue requiring immediate nursing assessment and intervention.
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