ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?
- A. Take the medication in the morning.
- B. Increase intake of potassium-rich foods.
- C. Report a decrease in urine output.
- D. Expect swelling in the lower extremities.
Correct answer: B
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.
2. Fred, a 12-year-old boy, is diagnosed with pneumococcal pneumonia. Which of the following symptoms would Nurse Nica expect to assess?
- A. Mild cough
- B. Slight fever
- C. Chest pain
- D. Bulging fontanel
Correct answer: C
Rationale: Chest pain is a common symptom associated with pneumococcal pneumonia. It can occur due to inflammation of the pleura or irritation of the lung tissue, leading to sharp or stabbing pain that worsens with breathing or coughing. While cough and fever are also common with pneumonia, chest pain is particularly significant in this case.
3. A patient with social anxiety disorder is starting cognitive-behavioral therapy (CBT). Which statement by the nurse best explains the purpose of this therapy?
- A. CBT will help you understand and change your thought patterns.
- B. CBT will focus on exploring your childhood experiences.
- C. CBT will teach you relaxation techniques to use in social situations.
- D. CBT will help you avoid situations that cause anxiety.
Correct answer: A
Rationale: Cognitive-behavioral therapy (CBT) is a structured, short-term psychotherapy that aims to help patients identify and change negative thought patterns and behaviors associated with anxiety. By understanding and altering these patterns, individuals can learn to manage and alleviate their symptoms effectively. Choice A is the correct answer as it accurately describes the purpose of CBT for social anxiety disorder. Choices B, C, and D are incorrect. B is incorrect because while childhood experiences may be explored, the primary focus of CBT is on thought patterns and behaviors in the present. C is incorrect because although relaxation techniques may be a component of CBT, the primary goal is not just to teach relaxation but to address underlying cognitive and behavioral patterns. D is incorrect because the goal of CBT is not avoidance but rather to confront and manage anxiety-provoking situations.
4. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?
- A. Initiate a dietary consult for a toddler
- B. Administer a glycerin suppository to a preschool-age child
- C. Evaluate gastric residual following intermittent feeding of an adolescent
- D. Transport a school-age child to x-ray
Correct answer: D
Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.
5. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?
- A. What is your marital status?
- B. How would you describe yourself?
- C. Are you employed?
- D. Do you have any children?
Correct answer: B
Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.
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